Optical Benefits Form - ESB Retired Staff Homepage
Optical Benefits Form - ESB Retired Staff Homepage
Optical Benefits Form - ESB Retired Staff Homepage
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This claim form should be completed and returned to the appropriate paying office* together withwhichever of the following documents are relevant:<strong>Optical</strong> 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 <strong>Benefits</strong>,<strong>ESB</strong>,Sean Mulvoy Rd,Galway- envelopes should be marked *Medical <strong>Benefits</strong>*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
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