Get 8665567655

Filling out the 8665567655 form is a straightforward process that can be completed online. This guide will provide you with clear instructions and support to ensure that your submission is accurate and complete.

Follow the steps to successfully complete your vision claim form.

1. Press the ‘Get Form’ button to obtain the vision claim form and open it in your preferred online editor.
2. Begin by completing Part 1 of the form, which is to be filled out by the employee. Provide your full name, the patient's date of birth, and the patient's full name as requested in fields one to three. Make sure to include the employee's Social Security number and indicate the patient's sex.
3. Answer whether the spouse is employed, the employer or group number, and the patient's relationship to the insured. Fill in the employee's address, ensuring it includes street, city, state, and zip code.
4. Indicate if the service was required due to an accident and provide a telephone number. If applicable, check the appropriate box to signify whether the patient has other vision insurance coverage. Be sure to sign and date the authorization in block number 12.
5. If you would like payment to be made directly to the physician, sign block number 13. If you have already paid the provider, do not sign this section and proceed to have the physician complete Part 2.
6. In Part 2, the physician will fill out all necessary information regarding the patient's examination. They should answer questions regarding previous glasses usage, whether new glasses are needed, and provide a diagnosis.
7. The physician must sign Part 2, confirming their qualifications to perform the reported services. After completing Part 2, proceed to Part 3 where detailed information regarding materials and professional services is recorded.
8. In Part 3, answer all questions concerning the services provided and associated charges. Ensure all fields are filled out completely to prevent processing delays.
9. Once all parts have been completed, review for accuracy. Save changes, prepare to download, print, or share the completed form as necessary.

Complete your vision claim form online today for a smooth submission process.