Out Of Network Vision Services Claim Form - 2013 Page 2
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Patient Information (Required)
Last Name
First Name
Middle Initial
Street Address
City
State
Zip Code
Birth Date (MM/DD/YYYY)
Telephone Number
-
-
-
-
Member ID #
Relationship to the Subscriber
(if applicable)
Self
Spouse
Child
Other
Subscriber Information (Required)
Last Name
First Name
Middle Initial
Street Address
City
State
Zip Code
Birth Date (MM/DD/YYYY)
Telephone Number
-
-
-
-
Vision Plan Name
Vision Plan/Group #
Subscriber ID #
(if applicable)
Date of Service (Required) (MM/DD/YYYY)
-
-
Request For Reimbursement –Please Enter Amount Charged. Remember to include itemized paid receipts:
Exam
Frame
Lenses
Contact Lenses - (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 without prior authorization from EyeMed Vision Care LLC for services rendered, 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.
Member/Guardian/Patient Signature (not a minor) ______________________________ Date: ________________
GEN POP
OON
*GEN POP*
*Out of Network*
Revision date05.2013
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Parent category: Legal