Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to access the VISION CLAIM FORM and open it in your preferred editing software.
2. Complete the employer and group number fields at the top of the form, ensuring you input accurate information.
3. Fill out the employee's social security number and name in the designated fields.
4. Indicate the relationship of the patient to the employee by selecting the correct option (self, spouse, child, or other).
5. If the patient has experienced any service-related accidents, mark yes or no in the relevant sections.
6. Specify the prescription details for both the right and left eye in the designated fields.
7. In the supplier information section, fill out the supplier’s name, address, and tax identification number.
8. Certify your qualifications as a provider by signing and dating at the bottom of the supplier information section.

Complete and submit your VISION CLAIM FORM online to ensure timely processing of your vision care benefits.