Get Bdentalb And Vision Bclaim Formb - Mc2207-03 - Mayo Clinic - Mayo

Filling out the Dental and Vision Claim Form is an essential step to ensure you receive reimbursement for eligible health care and dependent care expenses. This guide provides clear, step-by-step instructions to help you navigate the process efficiently and effectively.

Follow the steps to successfully complete the claim form.

1. Press the ‘Get Form’ button to access the claim form and open it in your editing platform.
2. In Section I, Member Information, fill in the account holder's last name, first name, address, city, state, ZIP code, birth date, and member ID number found on the membership card. If you are submitting dental or vision claims, indicate whether you have other coverage by selecting 'Yes' or 'No', and if 'Yes', be prepared to submit an Explanation of Benefits (EOB).
3. In Section II, Health Care Expenses, provide information for each expense that requires reimbursement. Enter the service date, select the expense type (medical, dental, or drugs/medicine), provide a detailed description of the service, include the name and relationship of the individual receiving care, and state the amount to be reimbursed. Complete separate rows for each expense.
4. In Section III, Dependent Care Expenses, similarly provide details for each dependent care expense. Input the provider's name, each dependent's name and age, the service dates, and the total amount to be reimbursed for work-related dependent care. Ensure accurate completion to avoid delays.
5. Complete the Provider Verification section if applicable, ensuring it is signed by the provider or attach an itemized receipt if they cannot complete it.
6. In Section IV, the Account Holder Certification, review the certification statement carefully. Then, sign and date the form, verifying that all shared information is accurate and eligible for reimbursement.
7. Once all sections are completed, you can save your changes, download the form, print it, or share it according to your filing preferences.

Prepare and submit your claims online today to ensure timely reimbursement!