Follow the steps to complete the form online:

1. Press the ‘Get Form’ button to access the Vision Benefits Request Refractive Eye Exam form and open it in your preferred editor.
2. Fill in the employer's name at the top of the form. Ensure that you write the name of the employer as it appears in your records, such as ‘Costco Wholesale Corporation’.
3. Enter the policy or group number provided by your employer or benefits administrator.
4. Provide your Social Security number in the designated field to identify you as the employee.
5. Input your birthdate in the format MM/DD/YYYY to confirm your identity.
6. Complete your name as it appears on your identification documents.
7. Enter your address, including the zip code, to ensure accurate record-keeping.
8. Provide your daytime telephone number for any necessary follow-up communication.
9. If you are submitting this form for a patient, fill in the patient’s information such as their Social Security number, name, and birthdate.
10. Indicate the patient's relationship to you by selecting from Self, Spouse, or Child.
11. Specify the patient’s sex by choosing Male, Female, or Other.
12. If applicable, indicate whether the claim is related to an accident and provide the date and time of the incident.
13. Select the appropriate check box indicating how claim payment should be assigned.
14. If the payment is assigned to the doctor, be sure to sign and date the authorization section.
15. Enter the diagnostic codes that apply to the examination in the designated section.
16. Complete the routine eye examination section by providing the exam date and selecting the correct CPT code that applies.
17. Fill in the total charge for the examination and indicate the amount paid by the patient.
18. Input the taxpayer identifying number for reporting purposes, as required by law.
19. Complete the patient’s account number and the doctor/supplier’s name and address.
20. The doctor or supplier should sign and date the form, certifying the accuracy of the information provided.
21. Review the completed form for accuracy, save your changes, and proceed to download, print, or share the form as needed.

Complete the Vision Benefits Request Refractive Eye Exam form online today to ensure timely processing of your benefits.