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Vision Claim Form Complete and send to Meritain Health P. O. Box 27810 Minneapolis MN 55427 Fax 1. 763. Exam Indicate the nature of disease injury or vision disorder Refraction Yes Tonometry Yes Date of examination Contact Lenses Yes Cataract Surgery Yes Name of provider performing services Examination Charge Amount paid by employee Signature of provider Degree/Title Lenses Provider s Social Security or Tax ID Number required by law Frames Date ordered Date dispensed Sphere Cylinder Axis Pair...
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