Deductible, Co-Payment, Co-Insurance And Rx Reimbursement Claim Form

MAIL TO:

NYC DISTRICT COUNCIL OF CARPENTERS WELFARE FUND

Administrative Services

DEDUCTIBLE, CO-PAYMENT,C0-INSURANCE, RX, AND POST-TAX PREMIUMS

Only, Inc

2017

REIMBURSEMENT CLAIM FORM -

PO Box 9005, Dept. 95M

Lynbrook, NY 11563-9005

FOR ACTIVE CITY CARPENTERS

516-396-5500 / 800-537-1238

CALENDAR YEAR MAXIMUM FOR 2017: ACTIVE MEMBERS-$1,290 per family

COVERED EXPENSES INCLUDE: Medical, Hospital, Dental and Prescription Drug Deductibles, Co-Payments, and Co-

Insurance under your group health plan and Prescription Drug Costs. (For prescription drug reimbursement, you must

submit proof that you are enrolled in a health plan that satisfies the minimum value requirement under the Affordable Care

Act (ACA).) You are also eligible for reimbursement of premiums that you pay with post-tax dollars for health plans that

satisfy the ACA minimum value requirement.

However, in accordance with Internal Revenue Code requirements,

premiums paid through payroll deductions on a pre-tax basis cannot be reimbursed.

PATIENT(S) INFORMATION

PATIENT NAME

CHARGES INCURRED

REIMBURSEMENT FROM ALL OTHER PLANS

NET OUT-OF-POCKET EXPENSES

TOTAL

MEMBER INFORMATION

MEMBER NAME

BIRTH DATE

MALE

FEMALE

ADDRESS

APT. NO.

CITY

STATE

ZIP CODE

MEMBER/S SOCIAL SECURITY NO.

DAYTIME TELEPHONE NUMBER:

EVENING TELEPHONE NUMBER:

XXX-XX

EMAIL ADDRESS:

IF YOU ARE ENROLLED IN A CITY HEALTH PLAN, PLEASE INDICATE INSURANCE PLAN AND ATTACH COPY OF YOUR INSURANCE ID

CARD.

AETNA EPO

EMPIRE HMO

GHI-CBP/EBCBS

HIP PRIME HMO

METRO PLUS GOLD

EMPIRE PPO

GHI HMO

HIP PRIME POS

VYTRA HEATLH

CIGNA HEALTH

PLANS

IF YOU ARE COVERED UNDER A PLAN OTHER THAN THROUGH THE CITY OF NEW YORK, PLEASE SEND A COPY OF YOUR INSURANCE

CARD AND A COPY OF YOUR SUMMARY OF BENEFITS AND COVERAGE (SBC).

Insurance Carrier:_____________________________________________________ Is this a Minimum Value Health Plan? ___ Yes ___ No

Employer Name: _____________________________________

Phone Number:__________________________________

IMPORTANT NOTICE

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIAL FALSE

INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO,

COMMITS A FRAUDULENT ACT, WHICH IS A CRIME.

MEMBER SIGNATURE

I HEREBY CERTIFY THAT EXPENSES CLAIMED HAVE NOT BEEN REIMBURSED, AND ARE NOT REIMBURSABLE UNDER ANY OTHER

HEALTH PLAN COVERAGE AVAILABLE TO ME OR MY DEPENDENTS. I HEREBY AUTHORIZE ANY INSURANCE COMPANY, PREPAYMENT

ORGANIZATION, EMPLOYER, HOSPITAL, OR PROVIDER, TO RELEASE ALL INFORMATION WITH RESPECT TO MYSELF OR ANY OF MY

DEPENDENTS WHICH MAY HAVE A BEARING ON THE BENEFITS PAYABLE UNDER THIS OR ANY OTHER PLAN PROVIDING BENEFITS OR

SERVICES. I HEREBY CERTIFY THAT THE INFORMATION I HAVE PROVIDED IN SUPPORT OF THIS CLAIM IS COMPLETE, TRUE AND

CORRECT AND THAT ALL CHARGES CLAIMED WAS THE AMOUNT BILLED.

REIMBURSEMENTS ARE PAYABLE TO MEMBERS ONLY.

______________________________________________________________

________________________________

SIGNATURE OF MEMBER

DATE

ACTIVE-DEDUCTIBLE-CO-PAY CO-INSURANCE AND RX REIMBURSEMENT FORM 2017

Deductible, Co-Payment, Co-Insurance And Rx Reimbursement Claim Form - 2017

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