VISION & HEARING FORM
(Fire and Police Contractual Pools: Note: A separate form must be used for each receipt)
NAME:_______________________________
TITLE:________________________________
DATE OF HIRE:________________________
Date product or service was received:__________________
Amount: Up to $300.00______________
Provider:_____________________________
Provider Address:_______________________
Provider Phone:_________________________
I certify that the above product was provided to me for my personal use and that I did
not use HSA funds to purchase this.
_____________________________________
Employee Signature
Original receipt and a copy of the applicable prescription must be attached along with
denial of coverage by Cigna.
Received in Personnel on_____________________________
Approved/Denied
Human Resources Director:______________________________ Date:_____________
Sent to Finance Department on_______________________
Reimbursement Form/Vision/Hearing
Created on
5/1/2008 12:22:00 PM
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