Benefit Claim Forms

The forms in this section are Adobe Acrobat Files. These are downloadable, printable publications containing full text and graphics. You will need to have the Adobe Reader installed to use these forms. If you do not have it, you can download it for free from  Adobe.

• F-66a Medicare Supplemental Plan Benefit Claim Form
  To request LRFA Medicare Supplemental Plan benefits, members must submit a completed LRFA F-66a along with all relevant Medicare documents.

• F-18 Health Care Benefit Request Form
  To request LRFA Health Care Plan benefits, member must complete and sign the benefit request form, F-18, and submit it along with all hospital and physician bills (or legible copies).

• F-46a Supplemental Health Care Benefit Request Form
  To request LRFA Supplemental Health Care benefits, member must complete and sign the benefit request form, F-46a, and submit it along with all itemized hospital and physician bills.

• F-104 International Travel Benefit Request Form
  To request LRFA International Travel Plan benefits, member must complete and sign the benefit request form, F-104, and submit it along with all itemized hospital and physician bills.

• F-103 Visitors from Abroad Benefit Request Form
  To request LRFA Visitors from Abroad benefits, member must complete and sign the benefit request form, F-103, and submit it along with all itemized hospital and physician bills.

• F-39 Mortuary Benefit Request Form
  To request LRFA Mortuary benefits, beneficiary or family member must complete and sign the benefit request form, F-39, and submit it along with approprate documentation.