VISION SERVICES CLAIM FORM

SURECARE BENEFITS, INC.

PLEASE COMPLETE THE EMPLOYEE AND PATIENT INFORMATION

Today's Date

DATE OF SERVICE

Employee Name

Member Identification Number

Address

City

State

Zip

Patient's Name

Patient's Date Of Birth

Email (Optional)

Phone

Patient's relationship to employee

Self

Dependent

PLEASE COMPLETE SERVICES AND MATERIALS RECEIVED. YOU MUST PROVIDE THE COSTS PAID. COSTS PAID MUST MATCH SUBMITTED RECEIPT(S).

Please Note: Receipts must be submitted together at the same time for services and materials purchased (even if purchased on different dates) to receive reimbursement.

SELECT CATEGORY

Code

Date

Paid

SELECT CATEGORY

Code

Date

Paid

SELECT CATEGORY

Code

Date

Paid

SELECT CATEGORY

Code

Date

Paid

SELECT CATEGORY

Code

Date

Paid

PLEASE ATTACH REQUIRED PROOF OF PURCHASE

MEMBER / EMPLOYEE CERTIFICATION

I certify that the information on this form is correct and authorize the Provider to release appropriate information necessary to process this claim to plan provisions.