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Reset Form Print Mail or Fax to SAMBA 11301 Old Georgetown Road Rockville MD 20852-2800 301 984-1440 800 638-6589 Fax 301 816-0191 Vision Care Claim Form To be completed by the member AND the service provider or attach itemized bill. For reimbursement the member must file the claim with SAMBA. Section 1 Member and Patient Information to be completed by the member Member Name Last First MI Member ID Sex Birth Date M F Member Address Street City State Zip Daytime Telephone Patient Name Last First MI Patient s relationship to member self spouse child Patient Address Street City State Zip Is this claim covered by any other group insurance If yes provide member name Last First MI Policy Number If yes provide other group insurance carrier name and address Yes No I acknowledge that the services listed below were received by me or my covered dependents. I authorize release of any information related to this claim to the Plan and any of its authorized representatives. Any reimbursement will be ....

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SAMBA is a not-for-profit federal employee benefit association with an array of insurance plans to meet your needs – including the comprehensive SAMBA Federal Employee Health Benefit (FEHB) plan, life insurance for you and your family, dental and vision insurance, long term disability, and much more.

A Medigap policy is different from a Medicare Advantage Plan. Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits. The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

Disadvantages of Medicare Advantage Limited service providers. If you choose one of the more popular Medicare Advantage plan types, such as an HMO plan, you may be limited in the providers you can see. ... Complex plan offerings. ... Additional costs for coverage. ... State-specific coverage.

Sponsored and administered by: the Special Agents Mutual Benefit Association (SAMBA) Who may enroll in this Plan: All Federal employees, Tribal employees, and annuitants who are eligible to enroll in the Federal Employees Health Benefits Program (FEHB) may enroll in the SAMBA Health Benefit Plan.

SAMBA is a not-for-profit federal employee benefit association with an array of insurance plans to meet your needs – including the comprehensive SAMBA Federal Employee Health Benefit (FEHB) plan, life insurance for you and your family, dental and vision insurance, long term disability, and much more.

If you are age 65 or older, or otherwise entitled to Medicare, SAMBA offers additional protection from the high costs of health care. Whether you are still working or retired, SAMBA and Medicare work together to reduce your out-of-pocket expenses for covered services.

The SAMBA Employee Benevolent Fund (EBF) provides a lump sum death benefit payment to the beneficiary(ies) of a participating deceased DOI employee. The benefit is usually paid within 24 to 48 hours after notification of death.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232