Ufcw Local 247 Benefit Trust Fund Form

FORM F1 UFCW LOCAL 247 BENEFIT TRUST FUND DRUG VISION EXPENSES FORM 318B 2099 LOUGHEED HWY. PORT COQUITLAM BC V3B 1A8 Tel 604-945-7607 Toll-Free 1-800-663-7977 INSTRUCTIONS Attach the original bills and receipts for all expenses and itemize them by providing all the information requested. Note Drug and vision bills and receipts other than those required for government drug plans are part of our records and will not be returned. Therefore please retain the itemization of expenses that will accompany our cheque or explanation for Income Tax purposes. IMPORTANT Please answer all questions. This claim will be returned to you if it is incomplete or contains errors. EMPLOYER / STORE EMPLOYEE MEMBER S NAME ID SOCIAL INSURANCE DATE OF BIRTH MO ADDRESS NUMBER STREET CITY DAY SEX YR PROVINCE POSTAL CODE BC Have you any other coverage which would pay a benefit for this claim If yes name of Employer and Insurance Co. Date of Claim mm dd yy Type of Vision Expense Pharmacy or Vision Total or Drug Name Care Provider Charge If additional space is needed attach separate sheet Yes No Circle one Pharmacy or Vision TOTAL OF ALL CHARGES CERTIFICATION CONSENT I understand that it is an offence to make a false or misleading statement regarding the personal and claims information provided herein and declare that the information is true correct and complete. I certify that the charges for the medical services and/or supplies which are identified on this form and for which receipts are attached were incurred by me on the recommendation and approval of an attending physician and were required in connection with the treatment of an injury or illness suffered by me. I authorize the use of my Social Insurance Number as an additional verification of my identity in the administration of my benefit entitlements. I understand that my Social Insurance Number will be kept in strictest confidence and will only be used for the specified purpose. communicate with me determine coverage and benefit entitlements process claims for expenses incurred satisfy any reporting requirements of the provincial and federal governments comply with civil and criminal law estimate future operating costs assess Plan performance accommodate audits of the Plan and if applicable transfer data to a new replacement plan* I hereby authorize the Board of Trustees and the service agencies they employ to collect record use disclose and if applicable destroy my personal information* I may review the information referenced herein to ensure that it is up-to-date and that I may withhold or revoke my consent for its use at any time. However I realize that if I withhold or revoke my consent for its use thereby limiting or restricting the ability to determine coverage and benefit entitlements my participation in the Plan may be impaired or cancelled* If I have coverage under another plan I hereby authorize the Plan Sponsor to disclose personal information about me in order to determine eligibility for coverage in the settlement of claims.