 VLSCS
HEALTH FUND APPLICATION
P.O. Box 39022, James Bay Postal Outlet, Victoria, BC V8V 4X8
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Who Are You ?
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Member's Name: ___________________________________________
Address:
__________________________________________________
City: _______________________ Postal Code:
_____________
Telephone: __________________ Email: ____________________
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What to do...
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FIRST: Attach all original receipts to the back of this form.
How many receipts have you attached? _______
SECOND: Attach proof of address and proof of income. (eg:
copies of driver's license, phone bill, and income tax document.)
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| PLEASE NOTE: If you receive funding from any
source, for any health product or service, you may not apply for
reimbursement from the Health Fund for those products or services. |
IMPORTANT
Misuse of the Health Fund:
1. Reconstructed or fraudulent receipts.
2. Reimbursement cheques cashed by someone other than you.
3. Requesting Health Fund monies for health care products or
services that are funded by other sources.
4. Any fraudulent circumstances as determined by the health Fund
committee.
In the event of misuse of the Health Fund, the funds must be
repaid in full. |
DECLARATION: I have read the entire Health Fund form. I understand and
agree to the policies stated (please keep copies of pages 1 & 2
for your records). I understand the information I have provided is
confidential and only shared with the Health fund Committee for the
purposes of determining eligibility. |
Please Sign Here:
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Dated: ______________________________
Request reimbursement for the month of: _____________
Member's Name: _________________________
Member's Signature: _______________________ |
| Thank you for your interest in the Health Fund. You
have given us an opportunity to support lesbians in our community! |
Committee Use Only:
Date Application Received: ___________________________________________
Date Approve ( ) _____________________________ Reimbursement
amount: $ _____________
Denied ( ) ___________________ (date
letter sent) Appealed ( ) yes ( ) no |
