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ILIUM WELFARE PLAN 1188 FRANKLIN STREET, SUITE 101 SAN FRANCISCO, CA 94109
(415) 6738500OPHTHALMOLOGY BENEFIT CLAIM FORM
TO BE COMPLETED BY EMPLOYEE:
Employee NameLocalEmployee Social Security Number:Reg.No.(Street
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How to fill out ilwu-pma-welfare-plan-medicare-claim-form-for
How to fill out ilwu-pma-welfare-plan-medicare-claim-form-for
01
Fill in your personal information such as name, address, and phone number.
02
Provide your ILWU-PMA Welfare Plan Member ID number and Medicare number.
03
Include details of the medical services received, including dates of service and healthcare provider information.
04
Attach any necessary supporting documentation such as receipts or explanation of benefits statements.
05
Sign and date the form before submitting it to the ILWU-PMA Welfare Plan.
Who needs ilwu-pma-welfare-plan-medicare-claim-form-for?
01
Members of ILWU-PMA Welfare Plan who are seeking reimbursement for Medicare-covered medical services.
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What is ilwu-pma-welfare-plan-medicare-claim-form-for?
The ILWU-PMA Welfare Plan Medicare claim form is used to request reimbursement for Medicare-covered expenses.
Who is required to file ilwu-pma-welfare-plan-medicare-claim-form-for?
Retirees covered under the ILWU-PMA Welfare Plan who have Medicare coverage are required to file the claim form for reimbursement.
How to fill out ilwu-pma-welfare-plan-medicare-claim-form-for?
The form must be completed with the patient's information, details of the Medicare-covered expenses, and any supporting documentation before submitting it for reimbursement.
What is the purpose of ilwu-pma-welfare-plan-medicare-claim-form-for?
The purpose of the form is to request reimbursement for Medicare-covered expenses incurred by retirees covered under the ILWU-PMA Welfare Plan.
What information must be reported on ilwu-pma-welfare-plan-medicare-claim-form-for?
The form requires details of the Medicare-covered expenses, patient information, Medicare card details, and any supporting documentation such as receipts or invoices.
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