VISION FORM - ClaimSecure 2026

1. Click ‘Get Form’ to open the VISION FORM - ClaimSecure in the editor.
2. Begin by entering the Group or Employer name at the top of the form. Next, fill in the Plan Member’s Full Name, Group Number, Certificate Number, and Date of Birth.
3. Provide the Plan Member’s Address, including Street, Apt/Suite (if applicable), City, Province, and Postal Code.
4. Identify your Vision Provider by filling in their Name and Phone Number. Ensure all details are accurate for seamless processing.
5. If claiming for dependents, complete their information including Date of Birth and Relationship to Plan Member. Include names as required.
6. Detail any prescriptions by indicating whether they are new or old. Fill in specifics like Sphere, Cylinder, Axis, and any relevant medical conditions.
7. List VISION EXPENSES by attaching original receipts and noting down the nature of each expense along with dates incurred.
8. Finally, review all entries for accuracy before signing and dating the form at the bottom. Ensure you do not staple receipts to the claim form.

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