Form Bcv-1 - Claim For Vision Care Expense For Non-Participating Providers

CLAIM INSTRUCTIONS

EMPLOYEE:

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Use this form to obtain reimbursement for services.

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Complete the employee section of the form.

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Sign and date the form after checking for completeness.

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Attach a copy of itemized receipts.

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Submit the form to:

NATIONAL VISION ADMINISTRATORS

P.O. BOX 2187

CLIFTON, NEW JERSEY 07015

If you have any questions, please contact BlueCross Vision at 800.905.4102

On behalf of Capital BlueCross, National Vision Administrators, LLC (NVA

) provides the network and assists in the administration of network management

services for the BlueCross Vision benefits program. NVA is an independent company.

Issued by Capital Advantage Assurance Company

, a subsidiary of Capital BlueCross. Independent licensees of the BlueCross BlueShield Association.

Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

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Parent category: Business