Laserfiche WebLink
<br /> <br />Category 2: Sensitive information <br />Category 2: For official use only / disclosure permissible by law. <br /> City of Everett <br />Police and Fire Pension Boards <br />Request to the Board <br />To be completed by LEOFF 1 member (or family) for submittal to the board. <br />Member Name ____________________________ (please print) <br />1. Diagnosis: __chronic incontinence____________________________________ <br /> <br /> <br />2. Prognosis: _chronic and incurable____________________________________ <br /> <br /> <br />3. Type of Treatment(s) or Procedure: __incontinence supplies_______________ <br /> <br /> <br />4. Cost of treatments/service: $ ___439.17______________________________ <br /> <br /> <br />5. Request to the board for this specific treatment or procedure: <br />Reimbursement request for incontinence supplies (briefs, barrier cream, wipes, and <br />chucks pads in the amount of $439.17_____________________________________ <br />(Examples can be found at everettwa.gov/pensionboards) <br />Return to: <br />City of Everett <br />Police and Fire Pension Boards <br />2930 Wetmore Ave, Ste 1-A <br />Everett, WA 98201 <br />Leoff1@everettwa.gov