Optical

Your eligibility for SEBF benefits are set forth in your collective bargaining agreement or participation agreement that applies to your employment. The following is information regarding the SEBF optical plan(s).

Davis Vision is offered for the Central New York area and Service Employees Benefit Fund Optical Plan is offered for the Buffalo area.

(Central NY Area)

Optical coverage through Davis Vision provides coverage for an exam, glasses or contacts every 24 months.

Copays for In-Network providers are:
Routine Eye Exam	$10
Eyeglasses	$25
Contact Lenses - In lieu of glasses	$25

Optional frames, lenses and coatings are available at additional costs.

See Davis Vision website or brochure for additional information.

You may use an Out-of-Network provider and receive a reimbursement of up to $120 from Davis Vision towards all routine services and materials every 24 months.

Please visit the Davis Vision Website at www.DavisVision.com or call 1-800-999-5431 to locate a Davis Vision Provider in your area.

Davis Vision Brochure

Service Employees Benefit Fund

(Buffalo Area)

Optical coverage through Service Employees Benefit Fund allows members to choose any eye care provider and receive either $60 every 12 months or $120 every 24 months towards routine exams, frames, lenses or contact lenses.

Please refer to the SEBF Optical Fact Sheet below for additional details.

SEBF Optical Fact Sheet

SEBF Optical Claim Form

Optical claims mailing address:
Service Employees Benefit Fund
PO Box 1240, Syracuse, NY 13201

SEBF Optical Claim Form

Please fill out the form below. Form field entries ARE encrypted on submission, and the email is sent over an encrypted channel,
however file attachments ARE NOT encrypted, but are attached to the email sent.

While we take every precaution possible to ensure your privacy and safekeeping of your information,
please ensure there is no confidential information on any attachments. If your attachment contains confidential information please fax to 315-701-0686 or mail to:
PO Box 1240
Syracuse, NY 13201

Reimbursement Election(Required)

$60.00 (every 12 months)

$120.00 (every 24 months)

Sections A and D must be completed. Section B must be completed only if patient is not the member.

A. MEMBER INFORMATION

Member's Name(Required)

First Middle Initial Last

Date of Birth(Required)

Social Security Number(Required)

Email(Required)

Phone(Required)

Member's Address(Required)

Street Address Address Line 2 City State ZIP Code

Employer(Required)

B. PATIENT INFORMATION

Complete only if patient is NOT the member.

Patient's Name

First Middle Initial Last

Patient’s relationship to member:

Self

Spouse

Child

Other

Date of Birth

C. ASSIGNMENT OF BENEFITS

Complete ONLY if you want the money to be sent to the provider.

Consent

I authorize payment of benefits, otherwise payable to me, to my eye care provider for services rendered indicated on the enclosed bill(s). I understand that I am financially responsible to the eye care provider for charges not covered by my Optical Plan.

Member's Name(Required)

I also agree that by entering my name and date in the boxes below that I am the party responsible for submitting this information to the SEBF and that this may serve as my electronic signature.

Date(Required)

D. MEMBER’S SIGNATURE

Member MUST sign all claims.

Member's Name(Required)

I also agree that by entering my name and date in the boxes below that I am the party responsible for submitting this information to the SEBF and that this may serve as my electronic signature.

Date(Required)

E. File Upload

Please remember that while the email is sent over an encrypted channel, file attachments themselves are NOT encrypted, so please ensure attachments do NOT contain any confidential information.

Please attach receipts / documentation for reimbursement:

Drop files here or

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 56 MB.

Name

This field is for validation purposes and should be left unchanged.

Service Employees Benefit Fund

SEBF Optical Claim Form

A. MEMBER INFORMATION

B. PATIENT INFORMATION

C. ASSIGNMENT OF BENEFITS

D. MEMBER’S SIGNATURE

E. File Upload

Syracuse Office

Buffalo Office

Additional Resources