Follow the steps to complete your Vision Care Claims Form effectively.

1. Click ‘Get Form’ button to access the Vision Care Claims Form and open it in your preferred editor.
2. In Part A, enter the patient’s name in the format of Last, First, Middle. Specify the patient's relationship to the employee by selecting 'Self', 'Spouse', or 'Child'.
3. Fill in the patient's date of birth and indicate the patient's sex by selecting 'M' for male or 'F' for female.
4. Provide the member's name in the same format as the patient’s name. Include the member's social security number and date of birth.
5. Complete the member's address and indicate the member's status by selecting one of the options: 'Active', 'Part Time', or 'Retiree'.
6. If the claim is due to an accident, provide details about the date, time, place, and how the accident occurred. Specify if the accident took place at work by selecting 'Yes' or 'No'.
7. Sign the authorization section, which allows health care professionals to share information relevant to the claims process. This signature should be from the patient or an authorized person.
8. In Part B, the doctor must indicate whether they are a participating or non-participating provider and fill out their name, address, phone number, and taxonomy information.
9. The doctor is required to certify that the examination services were performed, and they must provide their signature and the examination date.
10. Part C must be completed by the dispenser, who will check their participation status, and provide necessary details about the lenses or frames dispensed. The dispenser must also sign this section.
11. Review all entered information for completeness and accuracy, then save the completed form. You can print, download, or share the form as needed.

Complete your Vision Care Claims Form online today to ensure timely processing of your claim.