Optical, Hearing Aid & Tax Voucher Requests

Vouchers can only be requested, not printed, from this site.

Instructions:
After checking to see if you qualify for the benefit, select the type of voucher you would like from the pull-down menu located on line 1. Enter the name of the person you are requesting the voucher for in the box located on lines A through J (one name per box). Complete the member information and then select the submit button. You will receive your voucher within 7 business days of your request. If for some reason the Fund is not able to issue the voucher or additional information is needed, the Fund will contact you via the phone number you have supplied.

* These Fields Must be Filled in for your Request to be Processed

1. I am requesting a * voucher.
2. The person(s) I would like the voucher(s) for is (are):
A.		B.
C.		D.
E.		F.
G.		H.
I.		J.

Member Information
Member ID (BF#) or Last 4 Digits of SS#*
Member's Last Name*
Member's First Name*
Middle Initial
Date of Birth* (format: MM-DD-YYYY)
Mailing Address*
City*
State*
Zip Code*
Member's E-mail*
Day Telephone*
Telephone Type
Would you like to pick up the voucher?*	YesNo Please give us 24-hr notice
* These Fields Must be Filled in for your Request to be Processed
SUBMIT ONLY ONE FORM PER VOUCHER TYPE
If you have any questions please contact the Fund at 631-319-4099 or email us at . (Please put "Fund Question" in the subject line) Keep in mind we will not be able to answer personal claim information due to the HIPAA laws. You will need to call us and have your PIN or BF# handy.