Get Highmark Fillable Claim Form

Filling out the Highmark Fillable Claim Form online is a straightforward process that allows users to efficiently submit their vision care insurance claims. This guide will provide detailed instructions to help users navigate each section of the form with confidence.

Follow the steps to complete the Highmark Fillable Claim Form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the patient and insured (subscriber) information. Fill in the patient’s name, including the first name, middle initial, and last name.
3. Enter the patient's date of birth in the specified format.
4. Provide the insured’s name, including their first name, middle initial, and last name.
5. Enter the patient’s address, including the street, city, state, and ZIP code.
6. Select the patient's sex by checking the appropriate box.
7. Input the insured’s ID number as required.
8. Indicate the patient’s relationship to the insured by checking the relevant box: Self, Spouse, Child, or Other.
9. Input the insured’s group number or group name as applicable.
10. Indicate if the condition was related to the patient’s employment or an auto accident by selecting yes or no for each.
11. If there is other health insurance coverage, provide the name of the policyholder, plan name, address, and policy or medical assistance number.
12. Enter the insured’s address, including the street, city, state, and ZIP code.
13. Sign the authorization section for the release of medical information and request payment of benefits, including the date.
14. Proceed to the examining physician or optometrist’s information section. Fill in the purpose of the examination and other related details.
15. List any required examination details such as the date of examination and whether it included refraction or tonometry.
16. Complete the supplier's statement section by detailing the lenses and frames ordered, ensuring to include charges.
17. Finally, review all entries for accuracy, then save your completed form. You may choose to download, print, or share the form as needed.

Start filling out your Highmark Fillable Claim Form online today for a smooth claims process.