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1. Click ‘Get Form’ to open the Out of Network Vision Services Claim Form in the 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 (MM/DD/YYYY), and telephone number. Ensure all fields are completed accurately.
3. Next, provide Subscriber Information. Fill in the subscriber's last name, first name, middle initial, street address, city, state, zip code, vision plan name, and vision plan/group ID number.
4. In the Request For Reimbursement section, enter the amounts charged for services such as exams and lenses. If applicable, check the type of lenses purchased.
5. Finally, sign and date the claim form at the bottom. Attach any required itemized paid receipts before submitting.

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