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:
- Review the following form and make sure all of the information we've included is correct.
- Fill in any remaining fields that are blank.
- Sign the form and attach an itemized receipt.
- 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.
For IE8, here is the download