Out-Of-Network Reimbursement Form
member’s name _________________________________________________________________ date of birth _________________
address ________________________________________________________________________
city ______________________________________________________________________________ state _______ ZIP _________
member’s ID or SSN _________________________________________________________________________________________
name of group/employer _______________________________________________________________________________________
Patient Information
patient’s name _________________________________________________________________ date of birth __________________
relationship to member _______________________________________________________________________________________
if the patient is a child (and over the age of 18):
[] Is the child a full time student? [yes] [no] name of school _____________________________________________
[] Is the child physically impaired? [yes] [no]
Reimbursement Request Information
date services were received ________________________________________
services received (circle any that apply and provide the amount paid for each)
exam $________________
lenses single vision
bifocal
trifocal $________________
progressive
lenticular
lens options
tint $_________________
other* $_________________
*(includes scratch coatings, anti-reflective coatings, etc.)
frame $_________________
contact lenses $_________________
contact fitting &/or evaluation $_________________
provider/optical shop _________________________________________________________________________ phone ___________
address ____________________________________________________________________________________________________
city ______________________________________________________________________________ state _______ ZIP _________
Coordination of Benefits Information
If you are coordinating benefits with another insurance carrier, we need a complete copy of the Explanation of Benefits from your primary insurance carrier. The Explanation of Benefits must indicate the service(s) which were received, as well as the amount paid, denied, or applied to your deductible. This information can be obtained from the provider who performed your recent services.
Submit this form along with related receipts to
P.O. Box 997105
Sacramento, CA 95899-7105
