Blue View Visionsm Reimbursement Form
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1
2Blue View Vision
Reimbursement Form
SM
Please complete the following steps prior to submitting the claim form to Blue View Vision. Any missing or incomplete information may result in
delay of payment or the form being returned. Please complete and send this form to Blue View Vision within one (1) year from the original date of
service by the provider’s office.
When visiting a provider, you are responsible for payment of services and/or materials at the time of service. Blue View Vision will reimburse
1.
you for services according to your out-of-network reimbursement schedule.
Please complete all sections of this form to ensure proper benefit allocation.
2.
Blue View Vision will only accept itemized receipts that indicate the services provided and the amount charged for each service. The services
3.
must be paid in full in order to receive benefits. Handwritten receipts must be on the provider’s letterhead. Attach itemized paid receipts from
your provider to the claim form. If the paid receipt is not in US dollars, please identify the currency in which the receipt was paid.
Please indicate to whom the reimbursement should be sent: (
)
Subscriber
Patient
CHECK ONE
Sign the claim form where indicated.
4.
/ /
DATE OF SERVICE:
Patient Information:
FIRST NAME:
LAST NAME:
MI:
STREET ADDRESS:
CITY:
STATE:
ZIP:
/ /
PHONE:
BIRTH DATE:
Plan Information:
SUBSCRIBER NAME
FIRST NAME:
LAST NAME:
MI:
PLAN NAME:
SUBSCRIBER ID:
Request For Reimbursement – Please Enter Amount Charged. Remember to include itemized paid receipts.
Exam: $ 0.00
Frames: $ 0.00
Lenses: $ 0.00
Contact Lenses:
$ 0.00
(includes fit and follow-up; please submit all contact related
charges at the same time)
If lenses were purchased, please check type:
Single
Bifocal
Trifocal
Progressive
I hereby understand that I may be denied reimbursement for submitted vision care services for which I am not eligible. I hereby authorize any insurance
company, organization, employer, ophthalmologist, optometrist, and optician to release any information with respect to this claim. I certify that the
information furnished by me in support of this claim is true and correct.
Signature of Member/Guardian/Patient
______________________________________________ Date _____________
(not a minor)
To Fax: 866-293-7373
To Email:
To Mail: Blue View Vision
Attn: Vision Claims
P.O. Box 8504
Mason, OH 45040-7111
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of
independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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