Blue View Vision Claim Form

Blue View Vision Claim Form

Blue View Vision Claim Form

Blue View Vision Claim Form

Kennebec Eye Care​​​​​​​, P.A.

Out of Network Vision Services Claim Form


Patient Information (Required)

Last Name

First Name

Middle Initial

Street Address

City

State

Zip

Member ID #

Relationship to the Subscriber

Birthdate

Telephone Number

Subscriber Information (Required)

Last Name

First Name

Middle Initial

Street Address

City

State

Zip

Birthdate

Telephone Number

Vision Plan Name

Vision Plan ID

Subscriber ID #

Blue View Vision reimbursement checks are issued by EyeMed Vision Care. Look for an EyeMed envelope in the mail.

Date of Service

Request for Reimbursement
Please enter the amount charged. Remember to include itemized paid receipts.

Exam

Frame

Lenses

Contact Lens (submit all charges at the same time)

If lenses were purchased, please check type

I hereby understand I may be denied reimbursement for submitted vision care services for which I am not eligible. I hereby authorize any insurance company, organization employer, ophthalmologist, optometrist, and optician to release any information with respect to this claim. I certify that the information furnished by me in support of this claim is true and correct.

Member/Guadian/Patient Signature (not a minor)

Date

chance0524 none 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM 9:00 AM - 5:00 PM 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM Closed Closed optometrist https://www.google.com/maps/place/Kennebec+Eye+Care/@44.5537945,-69.6342705,17z/data=!3m1!4b1!4m5!3m4!1s0x4cb1e47e5bd98651:0x767e5e6208170243!8m2!3d44.5538151!4d-69.6319013 https://www.facebook.com/KennebecEyeCare/reviews/?ref=page_internal