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Get Superior Vision Reimbursement Form Online

Member Reimbursement Claim Form Use this form for reimbursement for services received from an out-of-network provider or when you ve utilized an in-store sale or promotion from an in-network provider. Subscriber Information Please print clearly Subscriber Name Daytime Phone Evening Phone Mailing Address City State Name of Employer Zip Patient Information Patient Name Date of Birth Authorization Number Full Time Student Yes // No Verification may be required Claim Information Single Vision Lenses Bifocal Lenses Progressive Lenses Date of Service Exam Frame Is the provider an in-network provider Provider Name Contacts Contact Lens Fitting Exam Extra Ad-Ons Other Phone Number If you saw an in-network provider Are you applying for reimbursement after using an in-store sale or promotion you pay in full and then submit your receipt to Superior Vision for reimbursement at the out-of-network rates. Subscriber Information Please print clearly Subscriber Name Daytime Phone Evening Phone Mailing Address City State Name of Employer Zip Patient Information Patient Name Date of Birth Authorization Number Full Time Student Yes // No Verification may be required Claim Information Single Vision Lenses Bifocal Lenses Progressive Lenses Date of Service Exam Frame Is the provider an in-network provider Provider Name Contacts Contact Lens Fitting Exam Extra Ad-Ons Other Phone Number If you saw an in-network provider Are you applying for reimbursement after using an in-store sale or promotion you pay in full and then submit your receipt to Superior Vision for reimbursement at the out-of-network rates. If you have co-pays these are paid to your in-network provider at the time of your visit. You are also responsible for paying for any services or materials that are not covered or that exceed your benefit plan coverage. If you paid in full for your service please provide a brief explanation as to why your provider did not bill us on your behalf. Mail or fax a copy of the itemized invoice or receipt imprinted with the provider s name and address along with this form to the contact information below. Member Reimbursement Claim Form Use this form for reimbursement for services received from an out-of-network provider or when you ve utilized an in-store sale or promotion from an in-network provider. Subscriber Information Please print clearly Subscriber Name Daytime Phone Evening Phone Mailing Address City State Name of Employer Zip Patient Information Patient Name Date of Birth Authorization Number Full Time Student Yes // No Verification may be required Claim Information Single Vision Lenses Bifocal Lenses Progressive Lenses Date of Service Exam Frame Is the provider an in-network provider Provider Name Contacts Contact Lens Fitting Exam Extra Ad-Ons Other Phone Number If you saw an in-network provider Are you applying for reimbursement after using an in-store sale or promotion you pay in full and then submit your receipt to Superior Vision for reimbursement at the out-of-network rates.

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