Vision Reimbursement Form
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DIRECTIONS FOR SUBMITTING A CLAIM
Complete ALL PARTS of the Claim Form. If treatment was received in the United States you do not need to complete PART C.
Attach all original itemized bills, statements and invoices for services and supplies.
Please make certain that all documents indicate claimant’s name, date of service, diagnosis and the itemized charges.
Any false statement, concealment or fraud shall render this insurance null and void and all claims hereunder shall be forfeited.
Vision
Reimbursement Form
PART A. To be completed by the claimant for all claims
Claimant/Patient Name:
(As it appears on ID card)
Group Name:
Male Female
Date of Birth:
___/___/___ (MM/ DD/YYYY)
Claimant’s Relationship to Primary Insured: Self Spouse Child Other
Name of Primary Insured:
(As it appears on ID card)
Insured ID #:
Male Female
Date of Birth:
___/___/___ (MM/ DD/YYYY)
Home Country Address:
Current Address: City:
State: Postal Code: Home Phone: Work Phone:
Communications should be sent via email to:
Are you a full-time student?
Yes No
If yes, please provide the following information:
Name of School:
Street Address: Phone:
City: State: Postal Code: Country:
Email:
How many months of the year are you residing in the U.S.?
ALTERNATE PAYEE INFORMATION
Name:
Street Address: Phone:
City: State: Postal Code: Country:
Email:
Please print legibly and complete ALL SECTIONS of this form. Mail, fax, or email completed form to:
Address: International Medical Group, Inc. Claims, P.O. Box 9162, Farmington Hills, MI 48333-9162 USA,
Call: +1.800.628.4664 or outside U.S. +1.317.655.4500; Fax: +1.317.655.4505
Email: customercare@imglobal.com
www.imglobal.com
