Out-of-network Reimbursement Form
Prior to printing this form, please verify that the member/dependent is eligible for services either by visiting
www.vbaplans.com or by calling VBA’s Customer Care Center at 1-800-432-4966. If the patient is not eligible
for services, NO payment will be processed.
ALL INFORMATION MUST BE COMPLETED ON THIS FORM
INSTRUCTIONS
1. Employee completes ALL parts of this
form. Please complete PART 1 before
printing this form.
2. A separate Reimbursement Form is
required for each family member.
3. Please attach all itemized receipts to
this form. Please be certain that your
itemized receipts match the information
entered below.
4. Mail or fax completed forms to VBA at the
address listed below within 90 days of
the Date of Service.
5. All reimbursements will be sent to
the employee’s address on file.
PART 1: TO BE COMPLETED BY EMPLOYEE (Please complete PART 1 before printing this form.)
EMPLOYEE’S FULL NAME
HOME ADDRESS
PATIENT’S FULL NAME
MEMBER/EMPLOYEE SIGNATURE DATE
RELATIONSHIP TO EMPLOYEE EMPLOYEE DATE OF BIRTH PATIENT DATE OF BIRTH
CITY, STATE, ZIP CODE EMPLOYER NAME
LAST 4 DIGITS OF SSN # WORK PHONE # HOME PHONE #
My signature certifies this claim is NOT related to occupational accident/injury and I authorize VBA to disclose any necessary information concerning this claim.
PART 2: USE A SEPARATE FORM FOR EACH FAMILY MEMBER
PRACTICE NAME
OD MD
EXAM FEE
ADDRESS
PHONE NUMBER DATE OF EXAM COMMENTS
CITY, STATE, ZIP CODE
EXAM
DISPENSING PRACTICE NAME IF DIFFERENT
ADDRESS
PHONE NUMBER
INSTRUCTIONS
CHARGESDATE ORDERED
CITY, STATE, ZIP CODE
Attach your receipts to this form and mail to:
Note: Your itemized receipts must include
the information indicated above. If your
receipts do not reflect the information
above, your claim cannot be processed.
Bifocal $________
Progressives $________
Tint $________
Anti reflective $________
Polycarbonate $________
Elective contacts $________
Lasik (if covered by plan) $________
Medically required contacts (attach doctor’s letter) $________
Charge for new frame (if any) $________
Total Charges
$_______
Single vision $________
Trifocal $________
Lenticular $________
Scratch coat $________
Photochromic $________
UV coating $________
Low vision aids $________
VBA
300 Weyman Road, Suite 400
Pittsburgh, PA 15236
Or fax form and receipts to:
412-881-4898
LENSES & FRAMES
*** THIS FORM IS FOR SERVICES THROUGH A NON-PARTICIPATING PROVIDER ONLY ***
click to sign
signature
click to edit
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