Vision Reimbursement Form
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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.
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:
How many months of the year are you residing in the U.S.?
Street Address: Phone:
City: State: Postal Code: Country:
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
Vision Reimbursement Form
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PART C. Complete for all treatment received outside of the United States.
Date of service
What type of
service and/or
name of drug
What was the
Type of
paid or billed
Total charge
paid or billed
Converted to
U.S. funds
Office use only
Account Holder’s Name:
Bank Name:
Bank Address: City: Country:
Currency of reimbursement: Bank 9 digit ABA number—U.S. banks:
Bank 8 or 11 digit SWIFT code—non-U.S. banks: Sort code:
Bank account number: Bank IBAN:
Intermediary Bank Details (if applicable):
Name of intermediary bank:
Intermediary bank SWIFT code: Intermediary bank account number:
PART B. PAYMENT DETAILS (Checks will only be issued to a United States address.)
Make payment to the provider
Make payment to primary insured
Reimbursement method
Bank ACH or wire transfer (complete below) Check
Make payment to alternate payee
Reimbursement method
Bank ACH or wire transfer (complete below) Check
Vision Reimbursement Form
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PART D. AUTHORIZATIONto be completed by the claimant for all claims.
I verify that all information contained in this form is true, correct, and complete to the best of my knowledge.
I authorize any licensed doctor, practitioner of the healing arts, hospital, clinic, health related facility, pharmacy, government agency, insurance company,
group policyholder, employee or benefit plan administrator having information as to the care, advice, treatment, diagnosis or prognosis of any physical or
mental condition, or the financial or employment status of the insured named below, to provide this information to International Medical Group®, Inc. or any
agent or administrator acting on its behalf.
I understand that I have the right to receive a copy of this authorization upon request. A copy of this shall be as valid as the original. This authorization is
valid for twelve months from the date signed.
Print Name of Insured: __________________________________________________________________
ID #:
Signature of Insured/Guardian: X ______________________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
I authorize payment of any benefits for eligible medical expenses to the provider or other supplier of services which is entitled to payment of the attached bills.
Signature of Insured/Guardian: X
Date: ___/___/___ (MM/ DD/YYYY)
Version 0719IN01200804A190731
If needed you can overnight packages to following address:
2960 North Meridian Street, Indianapolis, IN 46208