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This guide provides step-by-step instructions for completing the Samba Insurance Vision Care Claim Form. Whether you are a member or a service provider, this resource will help ensure your claims are submitted accurately and efficiently.

Follow the steps to complete the Samba Insurance Vision Care Claim Form.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. In Section 1, provide the member and patient information. Enter the member's name, ID, sex, birth date, address, and daytime telephone number. Additionally, fill in the patient's name, relationship to the member, sex, birth date, and address. Indicate if the claim is covered by any other insurance by checking 'Yes' or 'No'. If 'Yes', include the member name and policy number of the other insurance.
3. Read and acknowledge the statement regarding services received. Ensure to provide your signature in the space provided to authorize the release of information related to the claim.
4. In Section 2, the service provider must complete the exam information. Enter the date of service, diagnosis, type of exam, and test results. Fill out the specific details regarding the fee and whether dilation was performed.
5. In Section 3, the provider of the service/optician will complete the materials section. Provide details about the frames and lenses, including types and retail amounts. Ensure to indicate total billed amounts clearly.
6. After all sections are completed, review the form for any missing information. Once confirmed that everything is correct, you can save your changes, download, print, or share the filled-out form as needed.

Submit your Samba Insurance Vision Care Claim Form online today to ensure timely processing of your reimbursement.