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VISION REIMBURSEMENT CLAIM FORM
Employee Instructions:
1. Vision reimbursement form must be complete and clear. Failure to answer any questions or provide
proper documentation may delay payment.
2.
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How to fill out vision reimbursement form must
How to fill out vision reimbursement form must
01
Obtain a copy of the vision reimbursement form from your employer or insurance provider.
02
Fill out your personal information, such as name, address, and contact details, at the top of the form.
03
Provide details about the eye care provider or optometrist you visited, including their name, address, and contact information.
04
Indicate the date of your eye care appointment and the reason for the visit (e.g., routine eye exam, new prescription, etc.).
05
Attach all the necessary receipts and invoices related to the eye care expenses you wish to claim for reimbursement.
06
Double-check all the information you have provided on the form to ensure accuracy and completeness.
07
Submit the filled-out form along with the supporting documents to the designated department or address as instructed by your employer or insurance provider.
08
Keep a copy of the filled-out form and all the supporting documents for your records.
Who needs vision reimbursement form must?
01
Anyone who has vision insurance coverage and has incurred eye care expenses can fill out the vision reimbursement form. This form is typically used by employees who are covered under their employer's vision insurance plan or individuals who have purchased individual vision insurance policies. It allows them to claim reimbursement for eligible eye care expenses, such as eye exams, prescription glasses or contact lenses, and other vision-related services, as specified in their insurance policy.
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