Cirseiu House Staff Benefits Plan Direct Reimbursement Claim Form - 2009
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3HOUSE STAFF BENEFITS PLAN
How To File An Out-of-Network Claim
A. Fill out the Member/Employee information and Patient Information sections on the following
page.
B. If you have an itemized bill from your provider or from your online purchase (e.g.
) attach your itemized bill to the claim form. You do not need to complete the
Provider Information section as long as you have an itemized bill from your provider.
C. If you do not have an itemized bill, have your provider complete the Provider Information
section and list dates of service and expenses incurred.
D. Sign and date your claim form under Member/Employee Certification.
E. Mail your completed claim form to: Vision Care Processing Unit, P.O. Box 1525, Latham,
NY 12110.
(05/13)
(212) 356-8181 (F) (212) 356-8180 (P) 520 Eighth Avenue, Ste. 1200, New York, NY 10018
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