Blue View Vision Out-of-Network Claim Form - Anthem 2025

1. Click ‘Get Form’ to open the Blue View Vision Out-of-Network Claim Form in our editor.
2. Begin by filling out the 'Patient Information' section. Enter your last name, first name, middle initial, street address, city, state, zip code, birth date, telephone number, and member ID number.
3. Next, complete the 'Subscriber Information' section with the subscriber's details including their last name, first name, middle initial, and vision plan information.
4. In the 'Request For Reimbursement' section, input the amounts charged for services such as exams and lenses. Ensure you check the type of lenses if applicable.
5. Attach itemized paid receipts from your provider to the claim form. Make sure these receipts are clear and indicate services provided.
6. Finally, sign and date the claim form at the bottom before submitting it via mail or email as instructed.

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