Optical Benefits Form - ESB Retired Staff Homepage

CLAIM ON ESB MEDICAL BENEFIT SCHEMEOPTICAL/ HEARING AIDTo be completed by applicantName 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 claim is being made on behalf of a spouse/civil partner or a childdependant. A SPOUSE/CIVIL PARTNER who is in employment must FIRST apply to the Departmentof Social Protection, and if not covered by the Social Welfare scheme must submit their written reply.Name of person for who benefit is claimed: _____________________________________Relationship to ESB employee or pensioner: ____________________________________Note: If separated or divorced please advise address to where correspondence should be sent.SPOUSE/CIVIL PARTNER: Is your spouse/civil partner paying full Pay Related Social Insurance nowor has He/She in the past?If applicable, please give details of commencement and cessation of employment:______________________________________________________________________CHILD: Date of Birth of Child: _____________________(N.B Only children under 16 years are eligible)Have you or your spouse/civil partner received or are you entitled to receive benefit form Social Welfare orany other medical scheme in respect of all or any of the items covered by this application? If so, please giveparticulars:Do you or your spouse/civil partner have a medical card? _________________________I declare 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 Paid :Cheque No. :Certified :Approved :1/2

This claim form should be completed and returned to the appropriate paying office* together withwhichever of the following documents are relevant:Optical Benefit: Itemised receipt indicating the services providedOrThe Optician should complete, sign and stamp this side of the formHearing Aid: Receipt and certificate from Doctor recommending the purchase ofhearing aid(s)*Current staff , VSS staff and pensioners send completed forms to:Medical Benefits,ESB,Sean Mulvoy Rd,Galway- 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 € _________________________2/2