Get Individual Vision Benefit Rider Reimbursement Claim Form - Lifemap

This guide provides comprehensive, step-by-step instructions for completing the Individual Vision Benefit Rider Reimbursement Claim Form - LifeMap online. Filling out this form accurately ensures that your vision-related expenses are reimbursed efficiently.

Follow the steps to successfully complete your claim form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the primary insured’s name in the designated field. This is the individual whose coverage is associated with the vision expenses.
3. Input the member ID number accurately to ensure proper identification.
4. Complete the address section with the street, city, state, and ZIP code of the primary insured.
5. Fill in the primary insured’s phone number for any necessary follow-ups.
6. Provide the patient name, which may be the same as the primary insured or a family member covered under the plan.
7. Enter the name of the healthcare provider who rendered the service.
8. Specify the date on which the service was provided.
9. Indicate the relationship of the patient to the primary insured, such as spouse, child, etc.
10. Complete the provider’s address and phone number to facilitate any necessary communication.
11. Detail the service or item description for which you are claiming reimbursement.
12. List the cost associated with the service or item.
13. Ensure all required fields are completed to avoid delays in processing; claim forms with missing information will be returned.
14. Prepare photocopies of each receipt supporting your claim and submit them with the completed form. Note that original receipts will not be returned.
15. Review the form for accuracy and completeness before submitting it for processing.
16. Once you have filled out the form, save changes, and download or print a copy for your records before sending it.
17. Mail the completed form and receipts to LifeMap Assurance Company at the address provided.

Start filling out your Individual Vision Benefit Rider Reimbursement Claim Form online now to ensure a smooth reimbursement process.