Fillable Member Reimbursement Claim Form (Cossatot Community College of the University of Arkansas)

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Member Reimbursement Claim Form (Cossatot Community College of the University of Arkansas)

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Member Reimbursement Claim Form
Use this form for reimbursement of services received from an out-of-network provider, or when
you have utilized an in-store sale or promotion from an in-network provider.
Subscriber Information (Please print clearly)
Subscriber Name
Daytime Phone
Evening Phone
Mailing Address
City
State
Zip
Subscriber ID Number
Name of Employer
Patient Information
Patient Name
Authorization Number Full Time
Student*
*Verification may be required
Yes
No
Claim Information
Date
of
Service:
Exam: $
Frame:
$
Single Vision Lenses:
Contacts:
Bifocal Lenses:
Contact Lens Fitting Exam:
Trifocal Lenses:
Extra Ad-Ons:
Progressive Lenses:
Other:
Is the provider an in-network provider? Yes No
Provider
Name
Phone Number
If you saw an in-network provider:
Are you applying for reimbursement after using an in-store sale or promotion?
Yes No
If you see an in-network provider but choose to take advantage of a sale, coupon, or other in-store special, the provider
may require that you pay in full and then submit your receipt to Superior Vision for reimbursement at the out-of-network
rates.
If you have co-pays, these are paid to your in-network provider at the time of your visit. You are also responsible for
paying for any services or materials that are not covered or that exceed your benefit plan coverage. If you paid in full for
your service, please provide a brief explanation as to why your provider did not bill us on your behalf.
Mail or fax a copy of the itemized invoice or receipt imprinted with the provider’s name and address along with
this form to the contact information below. Please retain the original for your records.
Superior Vision
Attn: Claims Processing
P.O. Box 967
Rancho Cordova, CA 95741
Fax: 916.852.2277
Questions? Please call our Customer Service department at 800.507.3800
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Member Reimbursement Claim Form (Cossatot Community College of the University of Arkansas)

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Completed 3 September 2020

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