Direct Reimbursement Claim Form
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1Laser Vision Correction
Direct Reimbursement Claim Form
Important Information:
1. Use this form to request reimbursement for Laser Vision Correction services received.
2. Make sure that all sections are completed, that you and the providers(s) have signed the form, and all services, costs, and service dates have been entered (be
sure to attach a copy of the bill from your provider).
3. Please note that the member’s (or employee’s) signature is required on this form.
4. Mail completed form along with other documents to: Vision Care Processing Unit, P.O. Box 1620, Latham, NY 12110.
5. FOR PATIENTS RESIDING IN TN ONLY: Tennessee state law stipulates that it is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Member/Employee Information
* Your member Identification No. is the number by which the company that sponsors your vision benefits identifies you.
(PLEASE PRINT CLEARLY)
Member Name: _____________________________________________________________
Member Identification No.:_______________________
First
Middle Initial
Last
Mailing Address: _____________________________________________________________________________________________________________
Street
City
State
Zip
Business Phone: ________________________________________________
Home Phone: _______________________________________________
Area Code
Area Code
Patient Information
Patient Name:
________________________________________________________
Confirmation Number: ________________________
First
Middle Initial
Last
Relationship:
Member
Spouse/Domestic Partner
Child DOB: ______
Provider Information
Surgeon/Facility:
Name: _________________________________________________________________________________________________________________________ _
Address: ________________________________________________________________________________________________________________________
City: ________________________________________________________________ State: __________________________ Zip: ______________________
Federal Tax I.D. Number: _________________________________________________________________________________________________________ _ _
Phone Number: ______________________________________________________________________________________ _____________________________
Provider Signature: ____________________________________________________________________________________________ ____________________
Service
Date of Service
Expense(s) Incurred
1. Initial Evaluation
$
2. Lasik OD (Right Eye)
$
3. Lasik OS (Left Eye)
$
4. PRK OD
$
5. PRK OS
$
6. Follow-up
$
Total
$
Member/Employee Certification
I certify that the information on this form is correct and authorize the Provider to release
I authorize payment of my vision benefit reimbursement
any appropriate information necessary to process this claim to plan benefit provisions.
to the
provider,
supplier of services, or
patient above.
_____________________________________________________ ________________
______________________________________________ ________________
Employee’s or authorized person’s signature
Date
Employee’s or authorized person’s signature
Date
MS0004 4/9/14
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Parent category: Business