In the event you have a vision examination performed by a non-VSP member ophthalmologist, the Trust will pay 80% of the reasonable and customary charges for the exam. This benefit is available once every 12 months from the last date of service, and applies only to a non-VSP member ophthalmologist. This benefit DOES NOT apply to a non-VSP provider optometrist.

Mail a copy of the ophthalmologist's itemized billing to:

Harrison Electrical Workers Trust
A&I Benefit Plan Administrators, Inc.
1220 SW Morrison Street
Suite 300
Portland, OR
97205-2222

Include the following information:

1. Your name;
   
2. Address;
   
3. Social security number;
   
4. Patient's name (you, your spouse or dependent);
   
5. Date of birth; and
   
6. Patient's relationship to you.