Follow the steps to complete the MES Vision Patient Claim Form online.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Begin by filling in the patient’s name, including the last name followed by the first name, in the designated field.
3. Select the patient’s gender by marking the appropriate box for Male, Female, or Non-Binary.
4. Provide the Employee's Identification Number and the Employee's Name, ensuring the information matches the records of the insurance provider.
5. Indicate the relationship to the employee by selecting the appropriate option: Self, Spouse, Domestic Partner, Child, Domiciled Adult, or Disabled.
6. Enter the address of the patient, including city, state, and ZIP code.
7. Fill in the patient’s birthdate in the format of Month/Day/Year.
8. Provide the name of the employer and the group policy number as necessary.
9. Answer whether the care required was because of an injury or illness by selecting 'Yes' or 'No'.
10. If applicable, indicate if there is other vision coverage by answering 'Yes' or 'No', and providing the name of the carrier and policy number if answered 'Yes'.
11. Indicate if the patient is a full-time student by selecting 'Yes' or 'No', providing the school name if 'Yes'.
12. Review the declaration statement and sign with the date, confirming that the information provided is accurate.
13. Fill in the necessary fields for the examination data, including diagnosis, HCPC/CPT codes, and charges as required.
14. Complete the examiner/dispenser portion with the name, participating provider number, and email addresses for the doctor and dispenser.
15. Once you have completed all sections of the form, save any changes, and choose to download, print, or share the completed form if needed.

Complete your documents online with confidence and ensure your vision claims are submitted smoothly.