Out-of-Network Claim Form

Let's face it - no one likes paperwork. That's why we've completed an out-of-network claim form for you, based on the information you provided during your order.

To receive a check for any money you're owed, all you need to do is:

  1. Review the following form and make sure all of the information we've included is correct.
  2. Fill in any remaining fields that are blank.
  3. Sign the form and attach an itemized receipt.
  4. Mail the completed form and itemized receipt to your vision insurance company.

Please note: Not all insurance plans have out-of-network benefits, so please contact your insurance company to check benefits from out-of-network providers. Any missing or incomplete information may result in delay of payment or the form being returned. Your insurance company will notify you if it needs additional information.

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Patient Information








Enter as MM/DD/YYYY.


Subscriber ID's are assigned to people on your plan who aren't the primary plan member. Subscriber ID's are usually located on your vision insurance card.

Relationship to subscriber:

Subscriber information









Enter as MM/DD/YYYY.


Subscriber ID's are assigned to people on your plan who aren't the primary plan member. Subscriber ID's are usually located on your vision insurance card.

Enter as MM/DD/YYYY.

The name of your vision insurance company.


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

The amount you paid for contact lenses.

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