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O.N.T.E.A Benefit Trust Vision Care Service Record(This form to be maintained by the providers' office) SECTION I PROVIDER/PATIENT SECTIONMember Name:SECTION II COVERAGE SECTION___Member ID No.: ___

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Elder and special needs refer to the specific financial and medical needs of elderly individuals and those with disabilities.

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Family members or legal guardians of elderly individuals or individuals with special needs are required to file elder and special needs.

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Information such as income, assets, medical conditions, and care requirements must be reported on elder and special needs forms.

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