claim on esb medical benefits scheme - ESB Retired Staff Homepage

CLAIM ON E S B MEDICAL BENEFITS SCHEMEOPTICAL /HEARING AIDTo be completed by applicant:Name of ESB Employee or Pensioner: _____________________________Staff no. ____________In Superannuation Scheme from (Date, if known): ________________ ‘Phone no. _________________Location/Address: __________________________________________________________________________________________________________________________________________________________This section should be completed if the <strong>claim</strong> is being made on behalf of a spouse or a childdependant. A SPOUSE who is in employment must FIRST apply to the Department of Social &Family Affairs, and if not covered by the Social Welfare scheme must submit their written reply.Name of person for whom Benefit is <strong>claim</strong>ed: _____________________________________________Relationship to ESB Employee or Pensioner: ______________________________________________Note:If separated or divorced, please advise the address to where correspondence should be sent.SPOUSE:Is your spouse paying full Pay Related Social Insurance now or has he/she in thepast? If applicable, please give details of commencement and cessation ofemployment:_________________________________________________________________________CHILD:Date of child’s birth: _______________________________(N.B. Only children under 16 years are eligible)______________________________________________________________________________________Have you or your spouse received or are you entitled to receive benefit from Social Welfare or anyother medical scheme in respect of all or any of the items covered by this application? If so, pleasegive particulars:______________________________________________________________________________________________________________________________________________Do you or your spouse have a Medical Card?___________________I declare that the information I have given is true and complete to the best of my knowledge.Signed: ________________________________________Date: _________________FOR OFFICE USEAmount €Type of Benefit Dental/Optical/AuralWk/Month PaidCheque no.CertifiedPayment Approved

This <strong>claim</strong> form should be completed and returned to the appropriate paying office* together withwhichever of the following documents are relevant:Optical Benefit:Hearing Aid:Itemised receipt indicating the services providedOrThe Optician should complete, sign and stamp this side ofthe formReceipt and certificate from Doctorrecommending the purchase of Hearing Aid(s)* For current employees/staff on VSSStaff on Pensions Payroll:Payroll UnitE S BKilcruttin Business ParkTullamoreCo OffalyPayrollE S BLower Fitzwilliam StreetDublin 2- envelopes should be marked “Medical Benefits”______________________________________________________________________________________TO BE COMPLETED BY OPTICIANExamination Date: _________________Sight Examination:€ ___________________Supply or Repair of Spectacles1 pair Distance € ____________________1 pair Reading € ___________________Bi-focal/Varifocal spectacles or repairs thereto:Contact Lenses:(Once-off payment, unless there is a change in prescription )€ ___________________€ ____________________Total:€ ____________________P D 1068 (9/05)