Get Member Reimbursement Request Form - Advantica

Filling out the member reimbursement request form is essential for processing your vision claim effectively. This guide will provide you with clear instructions to ensure your form is completed accurately and submitted without delay.

Follow the steps to complete your reimbursement request form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the form, locate the Group Name/ID section and enter the group name or identification number provided by your benefit plan.
3. Next, fill in the Name of Subscriber field with the name of the person who holds the insurance.
4. Enter the Subscriber ID Number which is typically found on your insurance card.
5. Complete the Subscriber Address section with the current mailing address for the subscriber.
6. Indicate the Name of Individual Receiving Services, which may be different from the subscriber.
7. Provide the Date of Birth of the individual receiving the services.
8. Check the specific services that were received from the list provided. Make sure to review your plan for coverage of these services.
9. Attach your itemized receipt to the completed form, ensuring all necessary information is included.
10. Finally, review all entries for accuracy, save changes, and then download, print, or share the completed form for submission.

Complete your MEMBER REIMBURSEMENT REQUEST FORM online today to ensure your claim is processed efficiently.