Get Excellus Msa-69

Filling out the Excellus MSA-69 form online can be straightforward if you follow the correct steps. This guide aims to provide clear instructions for each section of the form, ensuring a smooth completion process for all users.

Follow the steps to complete your Excellus MSA-69 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the designated editor.
2. Begin by filling in the subscriber's name. This should be the person who holds the vision insurance policy.
3. Enter the Vision Policy ID number accurately, as this is crucial for processing your claim.
4. If applicable, provide the Medicare number in the designated field. Indicate whether the claim is related to a motor vehicle accident by checking 'Yes' or 'No.'
5. Fill out the accident injury date if you answered 'Yes' to the previous step.
6. Next, input the patient's name and gender, selecting either 'M' or 'F' as appropriate.
7. Indicate the patient's birthdate and their relationship to the subscriber, such as self, spouse, child, etc.
8. Check 'Yes' or 'No' to indicate if the patient has other eye care insurance, and if 'Yes,' provide the name and address of the other insurance company.
9. Input the other insurance contract/ID number if applicable.
10. The subscriber should sign and date the form, confirming that the information provided is accurate.
11. If a provider is completing the claim, they must include their signature and date in the specified area.
12. Review all entries to ensure accuracy and completeness before proceeding.
13. Once all fields are filled out, users can save changes, download, print, or share the completed form as needed.

Complete your Excellus MSA-69 form online now for a seamless experience.