City of Des Moines
LEOFF I MEMBER CLAIM FORM
Reimbursement of Medical/Dental*/Vision Expenses
Name: ________________________________________ Date of Birth: _____________
Street Address: _________________________________ Telephone: _______________
City: ________________________ State: _____________ ZIP: ___________________
OTHER SOURCES OF REIMBURSEMENT
Insurance/Medicare: _________________________________ Policy No.:_____________
MEDICAL CONDITION(S):______________________________________________
______________________________________________________________________
EXPENSES INCURRED
Date of Service
Description of Procedure
Provider Name
LEOFF I Responsibility
Total Claim (minus insurance/Medicare responsibility)--$
I have attached copies of billing statements, and other supporting documents.______ (initial)
The condition treated was not due to by licentiousness or abuse, and the expenses were solely for
necessary medical/dental*/vision service._________________ (initial)
It is my responsibility to pay for services before charges become delinquent. __________ (initial)
This claim contains no late charges, interest or missed appointments._____________ (initial)
*Dental bills are paid under the following condition of RCW 41.26.030 (22) (H) “…incurred by a
member who sustains an accidental injury to his or her teeth and who commences treatment by a
legally licensed dentist within ninety days after the accident…”
I HEREBY ATTEST that, to the best of my knowledge, the above information is true and
correct. I hereby authorize any service provider who has treated me for this condition to
release my medical records to the City of Des Moines LEOFF I Disability Board, or its
designee. Furthermore, I hereby consent to examination by any other physician the Board
may require. I understand that this consent is only for establishing my right to LEOFF I
benefits.
Signed: ___________________________________________ Date: ________________
LEOFF I Member
0.00
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