Deductible And Premium Reimbursement Claim Form - Seiu Local 503
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1DEDUCTIBLE AND PREMIUM
REIMBURSEMENT CLAIM FORM
Worker Name Last:
First:
Address:
Phone #:
Email Address:
SSN:
IF THE REQUIRED DOCUMENTS ARE NOT ATTACHED, YOUR REIMBURSEMENT CANNOT BE PROCESSED. Checks will
be mailed to address on file.
Out-Of-Pocket
Item
Month
Expense
Medicare Deductible
$
(Annually up to $2500, must attach Explanation Of Benefits from your Insurance Company)
Medicare Supplement or Rx
$
(Monthly up to $39, must attach Invoice & Receipt)
Medicare Part B Premium
$
(Monthly, must attach Invoice & Receipt)
Medical Premium
$
(Advanced if on a family plan CHECK HERE_____)
(Monthly, must attach Invoice & Receipt)
Medical Deductible
$
(Annually up to $2500 for both Medical & Rx, must attach Explanation Of Benefits from your Insurance Company)
Prescription Drug Deductible and/or Coinsurance
$
(Annually up to $2500 for both Medical & Rx, greater than $50 per prescription, must attach Invoice & Receipt)
TOTAL
$
Please Mail or Fax this form and supporting documents to:
Mail:
Oregon Homecare Workers Trust, PO Box 6, Mukilteo, WA 98275
Fax:
Oregon Homecare Workers Trust, 1-866-459-4623
Email:
Subject: OHCWT Reimbursement
Phone: 844.507.7554
I certify that the information provided on this form is true and that I have incurred the expenses described on this form solely for the
purpose of (a) purchasing Trust-approved health insurance through the applicable Exchange, (b) paying deductible or prescription co-
insurance expenses for benefits covered under such insurance, or (c) paying the applicable Medicare premium and/or deductible indicated
above. I also certify that I have not already received reimbursement for any of the above-listed amount and I will not seek reimbursement
of these amount from any other source.
Worker Signature:
Date:
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