San mateo care advantage vision insurance forms 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Information' section. Ensure you provide complete details including first name, last name, address, phone number, and date of birth. Select the gender and include any allergies.
3. Next, move to the 'Insurance Information' section. Enter the primary and secondary insurance names along with their respective patient ID numbers.
4. In the 'Prescriber Information' section, fill in the prescriber's details such as name, address, specialty, and contact information. If there is a requestor different from the prescriber, include their information as well.
5. Proceed to 'Medication / Medical and Dispensing Information'. Specify medication name, therapy type (new or renewal), dosage, frequency of administration, and any relevant clinical information that supports your request.
6. Finally, review all sections for accuracy before signing in the 'Attestation' area. Ensure all required attachments are included for a smooth submission process.

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