Get Ccpoa Piggyback

Filling out the Ccpoa Piggyback Vision Claim Form online can streamline the process of submitting your claim. This guide provides detailed, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to complete the Ccpoa Piggyback form.

1. Click ‘Get Form’ button to obtain the form and open it in your digital editor.
2. Fill in the CCPOA member/participant name, social security number, and address, including city, state, and ZIP code.
3. Provide your telephone number and the patient's name along with their birthdate.
4. Your eye doctor must complete the next section. Enter the name of the doctor or optometrist along with their address details (city, state, ZIP code) and business telephone number.
5. Fill in the date of the eye exam and the fee charged for the examination.
6. Indicate whether any lenses were purchased by circling 'YES' or 'NO.' If 'YES,' enter the fee charged for the lenses and specify the type (Single Vision, Bifocals, Trifocals, or Lenticular Lenses).
7. Indicate whether any frames were purchased by circling 'YES' or 'NO.' If 'YES,' enter the fee charged for the frames.
8. Ensure that your eye doctor signs and dates the form in the designated area.
9. Save the completed form, and ensure to attach an itemized receipt or VSP savings statement if applicable.
10. Review the completed form, then download, print, or share it as needed before mailing it to the CCPOA Benefit Trust Fund at the specified address.

Start completing your documents online for a smooth submission process.