Get State Of Maryland Vision Claim Form

This guide provides step-by-step instructions on completing the State Of Maryland Vision Claim Form online. By following these instructions carefully, you will ensure that your vision claim is submitted correctly and efficiently.

Follow the steps to successfully complete the vision claim form.

1. Click ‘Get Form’ button to access the form and open it in your preferred online application.
2. Begin by entering the subscriber's legal name, including the last name, first name, and middle initial. In the next section, provide the patient's legal name in the same format. Be sure to include the membership number associated with the subscriber.
3. Indicate the patient's sex by selecting either 'Male' or 'Female'. Enter the patient's date of birth, ensuring the correct month, date, and year format is used.
4. If you have a new address for the subscriber, check the appropriate box. Fill out the subscriber's address, including the street, city, state, and zip code.
5. Specify the patient's relationship to the subscriber using the available options, such as self, spouse, child, or other.
6. Record the telephone number and group number associated with the subscriber.
7. List any illnesses for which you are submitting bills, along with the date of first symptoms. If treatment resulted from an injury, indicate 'Yes' or 'No' and provide the date.
8. Answer whether the illness or injury was work-related. If there was an accident, describe what happened and provide the accident date.
9. Indicate if treatment resulted from an automobile accident and if the patient has Medicare coverage. If yes, specify both parts A and B.
10. Provide details of any additional health insurance coverage the patient may have. Fill in the policy holder's name and relationship to the patient, the insurance company name, the policy number, and the effective date of the coverage.
11. Once all fields are filled out correctly, certify the information by signing and dating the form as the subscriber. Make sure to attach any itemized bills that support your claim.
12. Finally, review all entries for accuracy, then save your changes, download the document, and print or share it as necessary for submission.

Complete your vision claim form online today for efficient processing of your health benefits.