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Superior vision authorization request form 2026
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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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Getting reimbursed when using an out-of-network provider: Download a Member Reimbursement Claim Form from our website, or call Customer Service at 800.507.Read more