Get Neuron Reimbursement Form

Neuron Direct Billing Claim Form - Optical Section 1 - Provider Name and Code to be completed by provider s personnel Provider Name Provider Code Section 2 - Member s Details to be completed by provider s personnel Membership No. Member s Name as it appears on the Neuron card Date of Birth Gender M F Telephone No. Section 3 - Service Information to be completed by treating optician Diagnosis Optical aids advised A. A pair of single vision lenses Cost B. A pair of bifocal vision lenses C. A pair of tri-focal vision lenses D. A pair of contact lenses E* Other specify Section 4 - Optician s Declaration Optician to affix signature on this section along with date I declare that I am the member s optician and that the particulars given are to the best of my knowledge true and correct. Signature Stamp of the optics store Date Section 5 - Patient s Declaration patient to affix signature on this section along with date I confirm I am the patient or the patient s parent or guardian if the patient is under 16 years of age and declare that all the particulars given above are to the best of my knowledge true and correct. I hereby consent to and authorise the medical provider health professional or other relevant medical establishment to provide and discuss any health/treatment details medical records or discharge arrangements past and present with and to the Insurer and/or Third Party Administrator. I agree that a copy of this consent shall have the validity of the original* Section 6 - Preauthorization Details Approval code Section 7 - Other Insurer s details if the treatment is accident - related or covered under another insurance policy please provide details Insurance company name Policy number Completed claim form along with supporting documents should be submitted to Neuron within the stipulated time-frame for submissions to be considered for payment as per relevant terms and conditions. A pair of single vision lenses Cost B. A pair of bifocal vision lenses C. A pair of tri-focal vision lenses D. A pair of contact lenses E* Other specify Section 4 - Optician s Declaration Optician to affix signature on this section along with date I declare that I am the member s optician and that the particulars given are to the best of my knowledge true and correct. A pair of contact lenses E* Other specify Section 4 - Optician s Declaration Optician to affix signature on this section along with date I declare that I am the member s optician and that the particulars given are to the best of my knowledge true and correct. Signature Stamp of the optics store Date Section 5 - Patient s Declaration patient to affix signature on this section along with date I confirm I am the patient or the patient s parent or guardian if the patient is under 16 years of age and declare that all the particulars given above are to the best of my knowledge true and correct. Signature Stamp of the optics store Date Section 5 - Patient s Declaration patient to affix signature on this section along with date I confirm I am the patient or the patient s parent or guardian if the patient is under 16 years of age and declare that all the particulars given above are to the best of my knowledge true and correct. I hereby consent to and authorise the medical provider health professional or other relevant medical establishment to provide and discuss any health/treatment details medical records or discharge arrangements past and present with and to the Insurer and/or Third Party Administrator.