Reimbursement Form

You can use this form to ask us to pay you back for eye exams and/or glasses or contact lenses. We can only pay for the services listed on this form and for services that you are covered for under your plan. If more than one person needs money back, please fill out a separate form for each patient.

Make sure you fill out every part of the form and sign it. If anything is missing, we might need to ask you for more information, which could slow down your payment.

Please include a receipt preprinted with the provider's name and address that shows:

• What you paid for

• How much you paid

• Date the service and/or eyewear were provided

Send the completed form and the receipt to:

P.O. Box 527271

Miami, FL 33152

For assistance, please call 1-855-610-1855.