Medical / Optical Refunds - Claim Form
Section 1 – Your personal details
Employee Number
Please post completed
form and receipts to
MRPC
An Post
Oliver Plunkett Street
PO Box 1234
CORK
Name
Grade
Work Location
Contact Number
Company Doctor
Section 2 – Your claim details
Employees who are members of the Company Medical Scheme
Prescriptions
Date Dispensed
(Note 1)
Cost
Doctors Fees
Date of visit
(Note 2)
Doctor’s Name
Fee
Employees who are (a) users of Display Screen Equipment (Note 3) or (b) employed on driving duties
Spectacles/Bi-focals
Date Dispensed
Cost
Eye Test
Date of visit
Optician’s Name
Fee
Section 3 – Your declaration
I confirm the following:





the particulars entered on this claim are correct
the claim is in strict accordance with An Post’s policy for refund of medical and / or optical expenses
the amounts claimed were wholly and necessarily incurred on my own behalf
any associated receipts are attached and will be forwarded with this claim form
a claim has not been made or will not be made to another entity in connection with the details which are the subject
of this claim
Signature

Date
D
D
M M Y
Y
Section 4 – Refund Centre use only
461 Meds
463 Doc
458 Test
459 Lens
Notes
1.
2.
3.
4.
Refund of prescription medicine expenses if prescribed by the Company-appointed Doctor (or by a private Doctor where there is no
Company-appointed Doctor in place)
Refund of GP fees is only available to employees in areas where there is no Company-appointed Doctor
Users of Display Screen Equipment must be referred to the Optician by their line manager (forms SH1 & SH3 required)
Various limits apply to Medical Scheme / Optical benefits. These are notified from time to time by Company Circular
© An Post 2014
Form MRPC 01 (Revn.1.0)
Revd. 02 October 2014