Dental, Optical, & Hearing Reimbursement Plan Form printable pdf download

NEWTON COUNTY SCHOOL SYSTEM DENTAL, OPTICAL, & HEARING REIMBURSEMENT PLAN

2016 PLAN YEAR PERIOD: JANUARY 1, 2016 – DECEMBER 31, 2016

**PLEASE NOTE ALL CLAIMS FOR 2016 MUST BE SUBMITTED BY 4/15/2017**

**SECTION I -TO BE COMPLETED BY EMPLOYEE**

Employee's Name: ________________________________________Last 4 of SS#:_________________

_________ Complete Address Section (ONLY if it has changed since last claim was submitted.)

NEW Home Address: ___________________________________________________________________

Phone:______________________________

Cell Phone: ______________________________

To ensure reimbursement along with this form please be sure you have included the following:

______ YES, I have included a statement of services.

______ YES, I have included proof of payment. (ie. Cash

receipt, charge card receipt, or cancelled check)

______ YES, I have had my PROVIDER complete

Participants please be aware if you cannot answer YES to

the previous 3 statements your claim WILL NOT be

Section II of this document.

reimbursed until all proper documentation has been

submitted.

I certify that the charges for which I am requesting reimbursement have been paid were made during the current reimbursement period, and are

for an employee of NCSS. False receipts and forgery may result in ejection from the plan and probable grounds for immediate dismissal. I also

authorize my provider of services to send to the Administrator copies of my records on any claim made, (if requested.)

Employee's Signature___________________________________ Date____________________________

*****SECTION II- TO BE COMPLETED BY PROVIDER (REQUIRED )*****

PROVIDERS PLEASE BE AWARE PERSCRIPTION SUNGLASSES, TEETH WHITENING,

AND PERSONAL ITEMS SUCH AS TOOTH BRUSHES ARE

NOT COVERED.

Patient’s Name: _______________________________________________ Patient’s DOB____________

Relationship to employee:_________________________

Date procedure performed: _________________

Participants and Providers please

Amount charged: $_____________________

be aware you may submit partial

Amount reimbursed (actual

or anticipated) by insurance

payments for services rendered. It

$_____________________

carrier:

is not necessary to wait until the

Net amount paid by patient:

$_____________________

full balance is paid.

BALANCE DUE: $_____________________

I certify that the procedure for the above named patient has been performed and the above amount was paid by patient:

Provider's Signature________________________________________ Date________________________

FAX CLAIMS TO: (706) 354-0999

QUESTIONS CALL: 1-888-685-4524

Mail claims to: CANNON FINANCIAL STRATEGISTS

PLAN ADMINISTRATOR OF THE NCSS D/O/H PLAN

649-8 SOUTH MILLEDGE AVENUE

ATHENS, GA 30605

Dental, Optical, & Hearing Reimbursement Plan Form

Related Articles

Related forms

Related Categories