Get Providence Health Plan Claims Address Form

Filing a claim for vision-related expenses can be straightforward when you have a clear guide. This document outlines how to accurately complete the Providence Health Plan Claims Address Form online to ensure you receive reimbursement for eligible services.

Follow the steps to fill out the form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide the insured’s information by filling in the date of birth and member identification number. Include the insured's full name, entering the first name, middle initial, and last name.
3. Enter the subscriber's details, including their full name and address. Ensure to include street address, city, and ZIP code.
4. Indicate the relevant vision services received by checking off the applicable options: vision exam, lenses, frames, or contact lenses. For each selected service, include the amount paid.
5. Attach proper documentation by ensuring any bills received from a licensed eye care provider are included. These must display the date of service, provider's name, address, tax identification number, diagnosis, service codes, and the amount charged. Note that cash register or credit card receipts are not accepted.
6. Review all provided information for accuracy. Once complete, save changes to the form, then download or print it for submission.
7. Mail the completed form along with a copy of the payment receipt or cancelled check to the specified address for Providence Health Plans.

Complete your vision claim form online today to ensure timely reimbursement.