Follow the steps to complete the Lehb form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter your payroll number or social security number in the designated field at the top of the form.
3. Fill in your name, address, city, state, and zip code in the respective fields to provide accurate identification details.
4. Provide the patient's name and date of birth to ensure the claim is associated with the correct individual.
5. Specify the date of service in the appropriate section to record when the services were provided.
6. Detail the description of services rendered. This may include examinations, frame names, and any other relevant services.
7. For any services provided, enter the charges in the respective fields next to each item listed, such as exams, frames, lenses, and other related costs.
8. Calculate the total charges for all services and input the total in the designated field.
9. Provide the spectacle or contact lens prescription details if applicable, ensuring to include any necessary costs.
10. Fill out the provider information section with the provider's name, address, city, state, zip code, social security number or tax identification number, and telephone number.
11. Sign in the member signature field to authorize payment directly to the provider.
12. Have the provider certify the services and materials indicated by signing in the provider’s signature section.
13. Once you have filled out all sections of the form, review for accuracy, save changes, and then choose to download, print, or share the completed form as needed.

Complete your Lehb form online today to ensure your vision claims are processed efficiently.