Member Reimbursement Claim Form - AllWays Health PartnersMember Reimbursement Claim Form - AllWays H 2026

1. Click ‘Get Form’ to open the Member Reimbursement Claim Form in our editor.
2. Begin by filling out the Subscriber Information section. Clearly print your name, daytime and evening phone numbers, mailing address, subscriber ID number, and employer's name.
3. Next, provide Patient Information including the patient's name, date of birth, and authorization number. Indicate if the patient is a full-time student by selecting 'Yes' or 'No'.
4. In the Claim Information section, detail the services received. List costs for single vision lenses, bifocal lenses, trifocal lenses, progressive lenses, and any additional services like contact lens fittings.
5. Indicate whether the provider is in-network and provide their name and phone number. If applicable, answer whether you are applying for reimbursement after using an in-store sale or promotion.
6. Finally, ensure you attach a copy of the itemized invoice or receipt with this form before submitting it to Superior Vision at the provided address.

Start using our platform today to easily complete your Member Reimbursement Claim Form for free!