Out-of-Network Vision Services Claim Form at a glance
What it is: The Out-of-Network Vision Services Claim Form is the itemized claim form to complete and sign to request reimbursement.
Where and when to file: First American Administrators, Inc. Attn: OON Claims, P.O. Box 8504, Mason, OH 45040-7111.
If you saw an out-of-network eye doctor and you have out-of-network benefits, your next step is to send your completed claim form, online or by mail.
What to bring and attach to Out-of-Network Vision Services Claim Form
Remember to include itemized paid receipts.
A filled-in Out-of-Network Vision Services Claim Form example: a claim for an exam and a frame
How to fill out Out-of-Network Vision Services Claim Form, box by box
Return the completed form and your itemized paid receipts
Return the completed form and your itemized paid receipts to: First American Administrators, Inc. Attn: OON Claims, P.O. Box 8504, Mason, OH 45040-7111.
Claim forms must be submitted within 15 months of the date of service.
Patient, Relationship to Subscriber
Enter the Patient Last Name, Patient First Name, MI, Birth Date (MM/DD/YYYY), Street Address, City, State, Zip Code and Patient Member ID #. †Required.
Under Relationship to Subscriber, mark Dependent or Self.
Doctor or Store Name where you received service
Enter the Doctor or Store Name where you received service. †Required.
Subscriber
Enter the Subscriber Last Name, Subscriber First Name, MI, Birth Date (MM/DD/YYYY), Street Address, City, State and Zip Code.
Vision Plan Name and Date of Service
Enter the Vision Plan Name, the Date of Service (MM/DD/YYYY), the Vision Plan Group # and the Subscriber Member ID #. †Required.
Service Type and Amount Charged
Enter Amount Charged for each Service Type: Exam, Refraction, Frame, Contact Lens, Contact Lens Fitting and Lenses.
Lens Type
Under Lens Type, Please Check Single, Bifocal, Trifocal, Progressive or Prem Prog.
Lens Options
Under Lens Options (if purchased), enter Amount Charged for Anti-Reflective, Polycarbonate, Scratch, Tint, UV, Other and Roll and Polish.
Total Amount Paid
Enter Total Amount Paid as shown on receipt, excluding sales tax.
Signature
Sign on the Member/Guardian/Patient Signature (not a minor) line and enter the Date. †Required.
By signing this claim form, you certify that you have read the applicable claim fraud warnings included with this form, and that all the information furnished by you is true and correct.
By signing, you authorize any insurance company, organization employer, ophthalmologist, optometrist and optician to release any information with respect to this claim.
Without prior authorization from EyeMed Vision Care LLC for services rendered, you may be denied reimbursement for submitted vision care services for which you are not eligible.
If your situation is different
You will be using electronic assistive devices to complete the form
If you will be using electronic assistive devices to complete the form, use the online form.
You may need to go out-of-network to receive care
Whether it's due to location or provider availability, you may need to go out-of-network to receive care. If this applies to you, please complete the following form. If not, please skip this section. Based from your home or office location, you may have the right to obtain in-network level of benefits with an out-of-network provider when: (i) you cannot schedule a visit within two-weeks, (ii) you are unable to locate a participating provider within a 10-mile radius in an urban-suburban area, or (iii) you are unable to locate a participating provider within a 20-mile radius in a rural area. You must submit a claim form to EyeMed for reimbursement.
Caution, this option is not available when you choose to use an out-of-network provider due to (i) your preference, (ii) when your personal schedule does not permit you to schedule an appointment with an available provider in two-weeks, (iii) or you are outside of your home or office location.
Check the boxes that apply; you acknowledge that you fit into one or more of the following criteria.
Should you fail to provide the requested information associated with the criteria you selected, you agree that EyeMed can process your claim as an out-of-network claim.
You were unable to schedule a visit within two-weeks with a participating provider
If you were unable to schedule a visit within two-weeks with a participating provider, provide the participating provider's name, location and contact information in which you attempted to schedule an appointment: Provider's Name, Provider Street Address, City, State, Zip Code and Provider Telephone Number (000-000-0000).
You were unable to locate a participating provider within a 10-mile radius in an urban-suburban area
If you were unable to locate a participating provider within a 10-mile radius in an urban-suburban area, provide the zip code in which you were attempting to locate a provider.
You were unable to locate a participating provider within a 20-mile radius in a rural area
If you were unable to locate a participating provider within a 20-mile radius in a rural area, provide the zip code in which you were attempting to locate a provider.
Common questions about Out-of-Network Vision Services Claim Form
Is there a penalty?
State Fraud Warning Statements, General Fraud Warning (5 continued): Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud and may be subject to fines and confinement in prison.
Sources
[1] Out-of-Network Vision Services Claim Form, EyeMed Vision Care (the Official source link on this page).
