Fillable MEMBER INFORMATION DIRECT REIMBURSEMENT CLAIM FORM SUBMIT THIS (FramesDirect.com)

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MEMBER INFORMATION DIRECT REIMBURSEMENT CLAIM FORM SUBMIT THIS (FramesDirect.com)

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  • 4 check-boxes
  • 23 other fields

Country of origin: US
File type: PDF

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DIRECT REIMBURSEMENT CLAIM FORM
MEMBER INFORMATION
PATIENT INFORMATION
PURCHASE INFORMATION
MEMBER ID #: ___________________________________________
GROUP #: _______________________________________________
MEMBER NAME: _________________________________________
DATE OF BIRTH: _________________________________________
MAILING ADDRESS: _____________________________________
CITY: ____________________________________________________
STATE: __________________________________________________
ZIP: _____________________________________________________
PHONE: _________________________________________________
ORDER #: ________________________________________________
PURCHASE DATE: _______________________________________
ITEM(S) PURCHASED: ____________________________________
FRAMES AMOUNT: _______________________________________
LENS AMOUNT: __________________________________________
CONTACT LENS AMOUNT: ________________________________
LENS TYPE (IF APPLICABLE):
Single Vision Progressive Bifocal Other
MAILING ADDRESS: _____________________________________
CITY: ____________________________________________________
STATE: __________________________________________________
ZIP: _____________________________________________________
PHONE: ________________________________________________
RELATIONSHIP TO MEMBER:
Self Spouse Child Other
PATIENT NAME: _________________________________________
DATE OF BIRTH: _________________________________________
PROVIDER: FramesDirect.com
ADDRESS: 2801 S I-35, Suite 170
CITY: Austin
STATE: TX
ZIP: 78741
PHONE: (800) 248-9427
MEMBER SIGNATURE: _________________________________________________________ DATE: _____________________________
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MEMBER INFORMATION DIRECT REIMBURSEMENT CLAIM FORM SUBMIT THIS (FramesDirect.com)

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Completed 31 January 2021

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