Transcription of State Vision Plan - michigan.gov
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State Vision Plan - michigan.gov
State Vision Plan Specialty glasses Employee Certification Form THIS FORM IS ONLY TO BE COMPLETED BY HR OFFICES on behalf of employees requesting specialty safety/computer glasses Has the employee already purchased Has the employee already purchased the Specialty Computer glasses ? the Specialty Safety glasses ? YES: The glasses are reimbursable through the Plan at YES: This form cannot be used as safety glasses are not the out-of-network rate. To start the process please reimbursable through the Plan. complete Section 1 and EyeMed will contact the employee. NO: Please complete the entire form as instructed. NO: Please complete the entire form as instructed.
State Vision Plan Specialty Glasses Employee Certification Form THIS FORM IS ONLY TO BE COMPLETED BY HR OFFICES on behalf of employees requesting specialty safety/computer glasses
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