Get Member Reimbursement Claim Form - Superior Vision

This guide provides a comprehensive overview of how to complete the Member Reimbursement Claim Form for Superior Vision online. By following these instructions carefully, you can ensure that your reimbursement request is processed smoothly and efficiently.

Follow the steps to fill out the form correctly

1. Click ‘Get Form’ button to receive the form and access it in the editor.
2. Begin by filling in the subscriber information section. Please provide your name, daytime and evening phone numbers, mailing address, city, state, zip code, subscriber ID number, and your employer's name. It is important to print clearly in this section.
3. Next, complete the patient information. Enter the patient’s name, date of birth, and authorization number. If applicable, indicate whether the patient is a full-time student by selecting 'Yes' or 'No'. Note that verification may be required for full-time status.
4. In the claim information section, itemize the services received. Fill in the costs for single vision lenses, bifocal lenses, trifocal lenses, progressive lenses, contact lens fitting exam, and any extra add-ons. Be sure to also include the date of service, the provider’s name, and whether they are an in-network provider.
5. For in-network providers, indicate if you are applying for reimbursement after using an in-store sale or promotion by selecting 'Yes' or 'No'. Provide a brief explanation if your provider did not bill Superior Vision on your behalf.
6. After completing the form, review all entries for accuracy. Gather the required itemized invoice or receipt from your provider that includes their name and address. These documents must accompany your filled form.
7. Save changes if you are working online. You can then download the completed form, print it, or share it as necessary. Finally, mail or fax the form and accompanying documents to the address or fax number provided in the instructions.

Complete your Member Reimbursement Claim Form online to ensure a timely reimbursement process.