Get Mvp Routine Eyewear Benefit Eyeglasses Contact Lens Reimbursement Form

Filing a request for reimbursement through the Mvp Routine Eyewear Benefit Eyeglasses Contact Lens Reimbursement Form is straightforward when you understand the necessary steps. This guide provides clear instructions to help you complete the form accurately and efficiently, ensuring you receive your benefits in a timely manner.

Follow the steps to complete your reimbursement request effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in your member information in the designated fields. You will need to provide your Member ID number, last name, first name, middle initial, address, city, state, zip code, phone number, and date of birth.
3. Enter the name, address, and phone number of your service provider. This is essential for the processing of your reimbursement.
4. Indicate the total number of receipts you are attaching to your claim. Each receipt should correspond to the services for which you are seeking reimbursement.
5. Specify whether this claim is for routine eyewear benefits by checking YES or NO. If yes, be sure to reference any relevant information provided on the reverse side of the form.
6. Select the type of service provided by circling all applicable options (eyeglass frames, eyeglass lenses, contact lenses) and enter the date of purchase.
7. Input the amount you paid for the service in the designated field. Ensure that this amount reflects the cost as outlined on your receipts.
8. Read the certification and authorization statement carefully. You must sign and date the form, confirming that the information provided is complete and accurate.
9. Once you have filled out all sections of the form and verified the accuracy of your entries, save the changes and download the document for your records.
10. Print the completed form along with any attached receipts, and submit it to MVP Health Care at the address specified for reimbursements.

Complete your reimbursement request online to ensure timely processing.