HEARING AID BENEFIT CLAIM FORM
Employee Name: ____________________________________________________
Address: __________________________________________________________
Last 4 digits Social Security Number: ____________________
Unreimbursed charges for hearing aids.
Payment is limited to $200 over a two-year period within the plan years.
Be sure your bills and/or receipts are copied and attached. Do not send originals.
This completed claim form should be mailed to:
The Preferred Group
P.O. Box 15136
Albany, New York, 12212-5136
Date(s): ___________ Total Amount of Claim: _______________
I certify that the above information is accurate and that the charges indicated were incurred by me or my dependents. I have not received payment for the amount of this claim from any other insurer, benefit fund, IRC 125 plan or by any other means.
Member’s Signature: ______________________________________________________
Date: ___________