Nyscopba retiree dental program 2026

1. Click ‘Get Form’ to open the NYSCOPBA Retiree Prescription Eyeglass and Contact Lens Reimbursement Claim Form in the editor.
2. Begin by filling in your personal information. Enter your last name, first name, middle initial, street address, city, state, and zip code in the designated fields.
3. Provide your home phone number and Social Security number. Ensure all details are accurate for smooth processing.
4. In the section for provider information, write down the name of the prescription eyeglass or contact lens provider you used.
5. Enter the amount paid as per your receipt. Select whether you are claiming for prescription eyeglasses or contact lenses by checking the appropriate box.
6. If you have received a reimbursement already this year, indicate 'Yes' or 'No' and provide the previously reimbursed amount if applicable.
7. Remember to attach the original copy of your paid receipt before submitting. This is crucial for reimbursement approval.
8. Finally, sign and date the form to certify that all information provided is true and accurate.

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