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Out-of-Network Claim Form

Out-of-Network Claim Form

  1. Fill in the form below.
  2. Sign the form & attach to an itemized receipt.
  3. Mail the signed, completed form & itemized receipt to your vision insurance company.
Please note: Not all insurance plans have out-of-network benefits, so please contact your insurance company to check benefits from out-of-network providers. Any missing or incomplete information may result in delay of payment or the form being returned. Your insurance company will notify you if it needs additional information.

Patient Information

Subscriber Information

Additional Information

(Your Insurance Provider)

Request for Reimbursement

Please enter amount charged. Remember to include itemized paid receipts.

I hereby understand that without prior authorization from my insurance carrier for services rendered, I may be denied reimbursement for submitted vision care services for which I am not eligible under my plan. I hereby authorize any insurance company, organization, employer, ophthalmologist, optometrist, and optician to release to my vision Insurance Plan any and all information necessary to process this claim. I certify that the information furnished by me in support of this claim is true and correct.

Member/Guardian/Patient Signature (not a minor): _________________________________________________
Date: ______________________