Get Out Of Network Vision Services Claim Form - Dental Select

Completing the Out Of Network Vision Services Claim Form - Dental Select can be a simple process when you understand each section. This guide will walk you through filling out the form online, ensuring that you provide all necessary information for a successful claim.

Follow the steps to easily submit your claim for out-of-network vision services.

1. Press the ‘Get Form’ button to acquire the form and open it in your preferred online document editor.
2. Begin by filling in the patient information section. Provide the patient's last name, first name, middle initial, street address, city, state, zip code, birth date in MM/DD/YYYY format, and telephone number.
3. Enter the member ID number if applicable and specify the relationship to the subscriber, selecting from options such as self, spouse, child, or other.
4. Next, fill out the subscriber information. This section requires the subscriber's last name, first name, middle initial, street address, city, state, zip code, and date of birth in MM/DD/YYYY format.
5. Indicate the vision plan name, vision plan/group number, and subscriber ID number if available.
6. Provide the date of service (in MM/DD/YYYY format) for the out-of-network visit and outline the amounts charged for various services, including exams, frames, lenses, and contact lenses.
7. Make sure to check the type of lenses, if purchased, by noting whether they are single, bifocal, trifocal, or progressive.
8. Read the authorization statement regarding reimbursement and ensure you understand the required signatures. Sign and date the claim form as the member, guardian, or patient who is not a minor.
9. Gather all itemized paid receipts from the out-of-network provider and ensure they are attached to your claim form. If receipts are not in US dollars, indicate the currency used.
10. Once the form is completed and all necessary documentation is attached, submit your claim. You can mail it to EyeMed Vision Care at the provided address or fax it to the specified number.
11. After submission, allow at least 14 calendar days for processing. Should you need to check the status of your claim, contact customer service using the number on your benefit identification card.

Start filling out your Out Of Network Vision Services Claim Form - Dental Select online now!