GVS UFT Welfare Fund | GVS UFT Welfare Fund

Direct Reimbursement Claim

SUBMIT ONLINE: Please fill out the information below and submit your claim.
SUBMIT BY MAIL: Click to download and print this form to submit by mail.

Complete and return this claim form to GVS. An itemized paid receipt and a copy of the eye exam prescription must accompany the claim form. To receive coverage for both the eye exam and glasses, you are required to obtain both services at the same location.

Member Information

Today's Date *

Enter one: UFT Member ID, Welfare Fund ID or last 5 of SSN*

Name *

Email*

Address *

City *

State *

Zip Code *

Phone *

DOB *

Patient Information

RELATIONSHIP TO MEMBER *

Self Spouse / Domestic Partner Dependent

GENDER*

Male Female

Name *

DOB*

Date of Service *

Address *

City *

State *

Zip Code *

Out of Network Provider Information

Name of Business*

Phone *

Address *

City *

State *

Zip Code*

Upload Store Receipt along with a copy of your eye exam RX
Please ensure your receipt image is clear and the text is readable, otherwise your claim may be delayed or denied.*

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To the best of my knowledge, the above information is true and correct and I or my dependent have received the service indicated above. In the event I receive an overpayment of benefits on my behalf or on behalf of my dependent, I am obligated to refund said overpayment to the Fund immediately.

No direct reimbursement will be made if service is rendered at a participating provider.

Direct Reimbursement Claim

Member Information

Patient Information

Out of Network Provider Information

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