This form is used to request reimbursement for services received from providers who do not participate in the vision network. Completion of this form does not guarantee reimbursement. The member must be eligible for services and materials on the date that services were provided.
Expenses for eye exams and eyewear can be claimed on this form. Only services listed on this form will be considered for reimbursement. Please submit a separate form for each patient.
Make sure that all sections are completed and that you have signed the form. If the form is incomplete, additional information may be required which may result in a delay of payment for eligible benefits.
The itemized receipt of payment, preprinted with the provider’s name and address, must be submitted with this form.
Please submit completed forms and a copy of the itemized receipt to
P.O. Box 668635. Miami, Florida 33166
For assistance please call 1-855-610-1855