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Eyemed Claim Form

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Out of Network
Vision Services Claim Form

Claim Form Instructions

Most EyeMed Vision Care plans allow members the choice to visit an in-network or out-of-network vision care provider. You only need to complete this form if you are visiting a provider that is not a participating provider in the EyeMed network. Not all plans have out-of-network benefits, so please consult your member benefits information to ensure coverage of services and/or materials from non-participating providers.

If you choose an out-of-network provider, please complete the following steps prior to submitting the claim form to EyeMed. Any missing or incomplete information may result in delay of payment or the form being returned. Please complete and send this form to EyeMed within one (1) year from the original date of service at the out-of-network provider’s office.

1. When visiting an out-of-network provider, you are responsible for payment of services and/or materials at the time of service. EyeMed will reimburse you for authorized services according to your plan design.

2. Please complete all sections of this form to ensure proper benefit allocation. Plan information may be found on your benefit ID Card or via your human resources department.

3. EyeMed will only accept itemized paid receipts that indicate the services provided and the amount charged for each service. The services must be paid in full in order to receive benefits. Handwritten receipts must be on the provider’s letterhead. Attach itemized paid receipts from your provider to the claim form. If the paid receipt is not in US dollars, please identify the currency in which the receipt was paid.

4. Sign the claim form below.

Return the completed form and your itemized paid receipts to:

Mail

EyeMed Vision Care

Attn: OON Claims

P.O. Box 8504

Mason, OH 45040-7111

Please allow at least 14 calendar days to process your claims once received by EyeMed.

Your claim will be processed in the order it is received. A check and/or explanation of benefits will be mailed within seven (7) calendar days of the date your claim is processed.

Inquiries regarding your submitted claim should be made to the Customer Service number printed on the back of your benefit identification card.

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Patient Information (Required)

Last Name

First Name

Middle Initial

Street Address

City

State

Zip Code

Birth Date

Telephone Number

Member ID # (if applicable)

Relationship to the Subscriber

Subscriber Information (Required)

Last Name

First Name

Middle Initial

Street Address

City

State

Zip Code

Birth Date

Telephone Number

Vision Plan Name

Vision Plan/Group #

Subscriber ID # (if applicable)

Date of Service (Required)

Request For Reimbursement – Please Enter Amount Charged. Remember to include itemized paid receipts:

Exam

Frame

Lenses

Contact Lenses - (please submit all contact related charges at the same time)

If lenses were purchased, please check type:

I hereby understand that without prior authorization from EyeMed Vision Care LLC for services rendered, 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/Guardian/Patient Signature (not a minor)

Date

FRAUD WARNING STATEMENTS

Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Arkansas: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

California: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud a policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.

Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

Idaho: Any person who knowingly and with intent to defraud or deceive any insurance company, files a statement or claim containing a false, incomplete or misleading information is guilty of a felony.

Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete or misleading information commits a felony.

Kansas: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

Nebraska: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a material false or deceptive statement is guilty of insurance fraud.

New Hampshire: Any person, who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in § 638.20.

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

New York: Any person who knowingly and with intent to defraud insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.

North Carolina: Any person with the intent to injure, defraud, or deceive an insurer or insurance claimant is guilty of a crime (Class H felony) which may subject the person to criminal and civil penalties.

Ohio: Any person who, with intent to defraud, or knowing that he is facilitating a fraud against an insurer, submits an application or files a false claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Oregon: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand (5,000) dollars and not more than ten thousand (10,000) dollars, or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances are present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

Rhode Island: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison

Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines and denial of insurance benefits.

Texas: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Vermont: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

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What the Eyemed Claim Form Is and when it’s used

The Eyemed Claim Form is the standardized document members or providers use to request reimbursement under EyeMed vision benefit plans. It collects member and provider identifiers, service dates, itemized charges, diagnostic and procedure codes, and receipts. Plans accept paper or electronic submissions; when submitted electronically, the form must meet applicable e-signature and privacy requirements such as ESIGN and HIPAA to ensure enforceability and data protection.

Why accurate completion matters for timely reimbursement

A correctly completed Eyemed Claim Form verifies eligibility, speeds adjudication, and reduces denials. Complete responses and required attachments help ensure claims are processed without manual follow-up, preserve member benefits, and provide an auditable record for appeals and employer reporting.

Why accurate completion matters for timely reimbursement

Who prepares and signs the Eyemed Claim Form

Typical users include members filing out-of-network reimbursements, clinical providers submitting claims on behalf of patients, and benefits administrators reconciling payments.

  • Members filing for out-of-network reimbursement for eye exams, frames, lenses, or contacts.
  • Providers submitting claims or supplying itemized receipts to support payment.
  • Employers and benefits teams reviewing claims for plan reconciliation and audit.

Roles determine which fields are mandatory, which attachments are required, and who must attest or sign the certification and assignment sections.

Step-by-step: completing the Eyemed Claim Form

Follow these sequential steps to prepare a clean, approvable claim submission.

  • 01
    1. Gather documents: Collect member ID, itemized receipt, and prescription.
  • 02
    2. Complete fields: Enter member and provider details accurately.
  • 03
    3. Attach receipts: Include itemized, dated receipts and proof of payment.
  • 04
    4. Submit: Send via the plan portal, mail, or permitted eSubmission method.

Frequently asked questions and common issues

Answers to common questions about forms, attachments, e-signatures, corrections, and privacy for Eyemed claims.


Need help? Contact support

Essential data fields to include on the form

Member ID: Exact member number
Subscriber Name: Full legal name
Provider NPI: National Provider Identifier
Date of Service: MM/DD/YYYY format
Itemized Receipt: Detailed charges list
Diagnosis Code: ICD or CPT code

Key components that make a complete Eyemed Claim Form

A professional submission groups member data, provider data, service details, financials, attachments, and signed certification for clarity and auditability.

Member information

Includes member and subscriber names, date of birth, and plan/member ID. Accurate demographic data prevents misrouting and supports eligibility verification during adjudication.

Provider details

Business name, address, phone, and NPI where applicable. Correct provider identifiers help insurers validate provider networks and apply negotiated rates.

Service description

Date(s) of service, itemized description (exams, lenses, frames, contacts), and applicable CPT or procedure codes for clinical services.

Costs and totals

Per-item charges, taxes, discounts, patient payment amounts, and total billed. Clear arithmetic reduces return-to-sender requests for clarification.

Attachments

Itemized receipts, prescriptions, and prior authorization if required. High-quality attachments decrease manual follow-up and speed payment.

Certification and signature

Provider or member signature and date certifying accuracy and, where applicable, assignment of benefits or release of information authorization.

Where to send the completed Eyemed Claim Form

EyeMed accepts claims via multiple channels; choose the method your plan specifies for the fastest processing.

  • Online portal: Upload form and attachments through the insurer's secure web portal.
  • Email submission: Use insurer-designated secure email addresses when permitted by the plan.
  • Mail: Send hard copies to the plan's claims processing address on the ID card.
  • Fax: Fax may be accepted; confirm the correct fax number with the insurer.

Customizing the form for online completion and eSubmission

Configure digital forms and workflows to capture required fields, attachments, and signer authentication before submission.

Field Configuration
Form template Lock required fields and provide inline help text.
Magic fields Auto-populate member data when available.
Conditional fields Show provider-only fields when provider role selected.
Signature field Enable electronic signature and timestamp capture.

Digital signing and integrations to support eSubmission

Use platforms that support secure uploads, audit trails, and needed integrations for records and benefits reconciliation.

  • Integrations: Connectors for Salesforce, NetSuite, and Google Workspace
  • File formats: Accepts PDF, DOCX, and image attachments
  • Authentication: Email, SMS, or advanced signer verification

Ensure any eSignature provider used supports HIPAA workflows and provides an audit trail to satisfy plan and regulatory requirements.

Timing and typical plan filing windows to watch

Claim filing deadlines and processing windows vary by plan; submit as soon as possible after service to avoid denial for late filing.

Plan filing deadline:

Many plans commonly require claims within 12 months of date of service; verify your plan's policy.

Electronic processing:

Electronic claims generally process faster than mailed claims; check plan materials for stated electronic timelines.

Appeal window:

Plans typically specify an appeal period for denials; follow insurer instructions exactly to preserve appeal rights.

Follow-up timeframe:

Allow insurer-specified processing time before calling; premature inquiries can add administrative overhead.

Proof retention:

Keep originals until claim is fully resolved and any appeal windows lapse.

Common mistakes that cause denials or delays

  • Incomplete member or subscriber numbers cause routing failures and require manual correction from the claimant after initial review.
  • Missing or non-itemized receipts force requests for additional documentation and extend adjudication timelines by several days or weeks.
  • Incorrect dates of service or transposed amounts create mismatches against provider records and often result in rejection.
  • Using initials instead of full signatures, or failing to indicate assignment of benefits, can prevent direct provider payments.

Consequences of incorrect or fraudulent claim submissions

Claim denial: No payment
Delayed reimbursement: Extended processing
Overpayment recovery: Insurer may seek repayment
Privacy breach: Potential HIPAA exposure
Duplicate claims: Possible audit flags
Fraud investigation: Legal consequences

eSignature vendor comparison relevant to Eyemed claim submissions

Basic vendor capabilities and starting prices for eSignature platforms commonly used to collect signatures and manage claim attachments.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial Yes, 7-day trial No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Real-world examples of common Eyemed claim scenarios

Two brief scenarios illustrate typical submissions and expected documentation for smoother processing.

Optometry Clinic Submission

A small clinic uploads an itemized receipt and prescription with the completed form

  • The insurer matches the NPI and member ID
  • The claim is adjudicated without follow-up after documentation verifies the billed services and payment applied.

Employee Reimbursement

An employee pays out-of-pocket for lenses and frames and completes the member section

  • They attach the original receipt and provider prescription
  • Reimbursement is issued after benefit eligibility is confirmed and copay applied.

Practical tips to reduce rework and speed payments

Apply these best practices to minimize administrative delays and preserve appeal rights when necessary.

Verify member details
Confirm member ID, subscriber name, and plan before submission. Cross-checking these fields with the ID card and employer plan documents prevents misrouted claims and manual verification requests.
Provide itemized documentation
Attach clear, itemized receipts showing provider name, service dates, and per-item charges. Low-quality or summarized receipts often trigger return-for-more-information requests and delay payment.
Use standard date formats
Enter dates as MM/DD/YYYY and ensure consistency across the form and attachments. Inconsistent date formats can cause adjudication systems to flag claims for manual review.
Keep copies and logs
Retain digital or physical copies of submissions, confirmation numbers, and correspondence. Accurate records support timely appeals and audit responses if a denial occurs.

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