SuperiorVision Member Reimbursement Claim Form

SuperiorVision Member Reimbursement Claim Form

SuperiorVision Member Reimbursement Claim Form

SuperiorVision Member Reimbursement Claim Form

Kennebec Eye Care​​​​​​​, P.A.

SuperiorVision Member Reimbursement Form

Use this form for reimbursement of services received from an out-of-network provider, or when you have utilized an in-store sale or promotion from an in-network provider.

Subscriber Information

Subscriber Name

Daytime Phone

Evening Phone

Mailing Address




Subscriber ID Number

Name of Employer

Patient Information

Patient Name

Date of Birth

Authorization Number

Full Time Student

*Verification may be required.

Claim Information

Date of Service



Single Vision Lenses

Bifocal Lenses

Trifocal Lenses

Progressive Lenses


Contac Lens Fitting Exam

Extra Ad-Ons


Is the provider an in-network provider?

Provider Name

Phone Number

If you saw an in-network provider:

Are you applying for reimbursement after using an in-store sale or promotion?

If you see an in-network provider but choose to take advantage of a sale, coupon, or other in-store special, the provider may require that you pay in full and then submit your receipt to Superior Vision for reimbursement at the out-of-network rates.

If you have co-pays, these are paid to your in-network provider at the time of your visit. You are also responsible for paying for any services or materials that are not covered or that exceed your benefit plan coverage. If you paid in full for your service, please provide a brief explanation as to why your provider did not bill us on your behalf.

Mail a copy of the itemized invoice or receipt imprinted with the provider’s name and address along with this form to the contact information below. Please retain the original for your records.

Superior Vision
Attn: Claims Processing
P.O. Box 967
Rancho Cordova, CA 95741

Questions? Please call our Customer Service department at (800) 507-3800

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