Get Blue View Vision Out Of Network Vision Services Claim Form

Filling out the Blue View Vision Out Of Network Vision Services Claim Form online is a straightforward process designed to help users obtain reimbursements for vision services received from non-participating providers. This guide provides step-by-step instructions to ensure you fill out the form accurately and efficiently.

Follow the steps to complete your claim form seamlessly.

1. Click ‘Get Form’ button to retrieve the claim form and open it in an editable format.
2. Begin by filling out the 'Patient Information' section, including the last name, telephone number, member ID number, and relationship to the subscriber. Choose from the provided options: self, spouse, child, or other.
3. Next, complete the 'Subscriber Information' section. Here, include the subscriber's last name, first name, middle initial, street address, city, state, zip code, telephone number, vision plan ID, and birth date in the required format.
4. In the 'Date of Service' field, provide the date on which the vision services were performed, following the specified format.
5. Proceed to the 'Request For Reimbursement' section, where you must enter the amount charged for each service. Be sure to include itemized paid receipts from your out-of-network provider, detailing the specific services performed.
6. If contact lenses were purchased, check the applicable type—single, bifocal, trifocal, or progressive, as indicated in the form.
7. Sign and date the claim form at the bottom. Remember, as the claimant, you must certify that all information provided is accurate and true.
8. Once the form is complete, you can save the changes, download it, print it, or share it as needed. Finally, return the completed form and itemized paid receipts to the specified mailing address for Blue View Vision.

Complete your Blue View Vision Out Of Network Vision Services Claim Form online today to ensure you receive your reimbursements quickly.