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III-A Subscriber Name: Patient Name: Mailing Address: City, State, Zip: Email: Phone: III-A Agency/Employer: Check written to: Documentation Required Amount Paid Receipt EOB Paid Receipt Invoice Paid Receipt Hearing Protection Definition: Hearing protectors reduce the noise exposure level and the risk of hearing loss. Internal Claim Form This form must be completed by the member and submitted with an invoice or receipt. If you have questions, please contact III-A Benefits Manager at [PHONE REDACTED] Air Ambulance Service Type Acupuncture Reimbursement Date: Hearing Aid Reimbursement (pay member) Hearing Aid Payment Request (pay provider) Hearing Protection Reimbursement (see below) Other: Total Payment Signature: By signing this form, you attest that you will not seek additional reimbursement, including vouchers or any other form of prescription coupons. The signor also attests that the submitted invoice has been paid in full. Approved Types of Hearing Protection: • Earplugs: pre-formed and hand-formed (without radios) • Noise Muffs: all authorized (without radios ) • Ear Canal Caps • Helmets Submit completed claim form and invoice or receipt to: Scan & Email: [EMAIL REDACTED] Fax: [PHONE REDACTED] Mail to: III-A, Attn: Internal Claims, PO Box 190477, Boise, ID 83719 0.00