MAIL COMPLETED FORM TO: 
FITZHARRIS & COMPANY, INC. 
VISION CARE 
STATEMENT OF CLAIM 
PO BOX 9182 
FARMINGDALE, N.Y. 11735 
(516) 777-2244 * FAX: (516) 777 777/ 78 
PART 1 TO BE COMPLETED BY EMPLOYEE/MEMBER 

1.Patient Name: 2.Relationship to Member: 
self spouse child other 
3.Sex: 
M F 
4.Patient Birthdate: 
Mo Day Year 
5.Patient if full time student: 
School: City: 
6.Member Birthdate: 7.Marital Status: 
married single 
divorced widowed 
8.Spouse's Name: 9.Spouse's Birthdate: 10.Spouse's Soc. Sec. #: 
Mo Day Year 
11.Insured Name (first,middle,last): 12.Member Soc. Sec. #: 13.Group Name: 
14.Mailing Address: 15.Other Family Members Employed?: 
If yes indicate: 
yes 
Name: Soc. Sec. #: 
no 
City, State, Zip: 
17.Is patient covered 
by another plan? 
yes no 
Plan Name: Union Local: Group #: Carrier Name/Address: 

TO: All providers of medical services and supplies, employers, insurance institutions and other organizations. I authorize release to Fitzharris & Co., my employer or 
other representative any information, including medical, employment and benefit information required for claim processing or plan administration. This authorization is 
valid for one year after the date signed. A copy of this authorization shall be as valid as the original. I understand that I may request a copy of this authorization. 

Benefits assigned to provider of services: 


yes 
no 
Any person who knowingly, and with intent to defraud any fund or other person, files an application for insurance or statement of claim containing any materially 
false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulant insurance act, which is a crime, 
and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. 

SIGNATURE OF ELIGIBLE MEMBER:___________________________________________________________________ DATE:_____________________ 

PART 2 TO BE COMPLETED BY OPTOMETRIST 

1.Supplier: 
2.Mailing Address: 
7.Is treatment result 
of occupational 
illness or injury?: 
yes no If yes, enter brief description & dates: 
8.Is treatment a result of auto accident?: 
3.City, State, Zip: 9.Other accident?: 
4.Soc.Sec # or T.I.N.: 5.License #: 6.Phone #: 10. Are any services covered by another plan?: 
11.Description of servicesA. Examination 
Date of sevice Fee 
11.Description of servicesF. Lenses Only 1.single vision 
Date of sevice Fee 
B. Single Vision w/Frame 2. Bifocal 
C. Bifocal w/ Frame G. Contact Lenses 
D. Frame Only H. Other 
E. Tint I. Total charges 
12.PLEASE COMPLETE THE FOLLOWING: 
A. Were lenses prescribed as a result of eye surgery? yes_____ no_____ C. Indicate Diagnosis or nature of disease or visual disorder _______ 
If yes, please specify procedure: ________________________________ D. If tinted glasses were furnished, were they specifically supplied 
for medical reasons? Yes___________ No_________ 
B. What is patients present degree of visual acuity? 
corrected _________________ uncorrected________________________ 
E. Please sign below: 
Signature:____________________________ Date:__________ 

PART 3 EMPLOYER/PLAN ADMINISTRATOR 

Member: Member ID #: Group Name: Policy #: Division: 
Date Benefits Became effective: 
Month Day Year Month Day Year 
EMP DEP 
Date Terminated: 
Mo Day Yr 
Authorized Signature: Date: 

Plan Administrator Copy