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Click ‘Get Form’ to open the superior vision authorization request form in the editor.
Begin by filling out the Subscriber Information section. Clearly print your name, daytime and evening phone numbers, mailing address, city, state, zip code, subscriber ID number, and employer name.
Next, move to the Patient Information section. Enter the patient's name, date of birth, and authorization number. If applicable, indicate if they are a full-time student.
In the Claim Information section, specify details for lenses (single vision, bifocal, trifocal, progressive) and any additional services like contact lens fitting exams or extra add-ons. Include the date of service and provider information.
Indicate whether the provider is in-network and if you are applying for reimbursement after using an in-store sale or promotion. Provide a brief explanation if necessary.
Finally, ensure you have all required documentation ready to mail or fax along with this form to Superior Vision Services.

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Versions	Form popularity	Fillable & printable
2019	4 Satisfied (37 Votes)
2009	4.9 Satisfied (49 Votes)

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