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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 paid to the member. Signature Required Member s Signature Date Exam Information to be completed by ophthalmologist/optometrist or attach itemized bill Date of Service Diagnosis Type of Exam Eyeglasses Date Ordered Sphere Cylinder Daily Wear Contacts Axis Extended Wear Contacts Prism Add Exam Fee Dilation L R Provider Name Provider Address Street City State Zip Provider/Representative Signature Provider Telephone Provider FTIN Date Materials to be completed by provider of service/optician or attach itemized bill Frames - Retail Amount Date of Purchase DO NOT MARK IN THE BOXES BELOW* Lens Type Options Retail Single Vision Polycarbonate Solid Tint Bifocal Progressive Trifocal Scratch Coating Lenticular Other Contacts Frame Soft Photochromic Daily Wear A/R Coating Extend Wear Ultra-Violet Total Billed Glass Lenses Gradient Tint Exam Hard Visit our website at www. 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. I authorize release of any information related to this claim to the Plan and any of its authorized representatives. Any reimbursement will be paid to the member. Signature Required Member s Signature Date Exam Information to be completed by ophthalmologist/optometrist or attach itemized bill Date of Service Diagnosis Type of Exam Eyeglasses Date Ordered Sphere Cylinder Daily Wear Contacts Axis Extended Wear Contacts Prism Add Exam Fee Dilation L R Provider Name Provider Address Street City State Zip Provider/Representative Signature Provider Telephone Provider FTIN Date Materials to be completed by provider of service/optician or attach itemized bill Frames - Retail Amount Date of Purchase DO NOT MARK IN THE BOXES BELOW* Lens Type Options Retail Single Vision Polycarbonate Solid Tint Bifocal Progressive Trifocal Scratch Coating Lenticular Other Contacts Frame Soft Photochromic Daily Wear A/R Coating Extend Wear Ultra-Violet Total Billed Glass Lenses Gradient Tint Exam Hard Visit our website at www..

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