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Claim submissionsmade easyIf you saw an out-of-network eye doctor and you haveout-of-network benefits, your next step is to send acompleted out-of-network claim form. Here’s how:Online–OR–Click below to completean electronic claimform. Go green andget paid faster.By mailComplete andreturn the followingpaperwork.Access FormIf you will be using electronic assistive devices tocomplete the form, please use the online form.Claim forms must be submitted within 12 months ofthe date of service. For complete terms and conditions,review the claim form.Stay in-network and save onyour next visit *CHOOSE AN EYE DOCTORWith thousands of providers across the nation, you cansee who you want to see, when and where you wantto see them. Whether it’s an independent eye doctor,popular retailer or even online, you have options.Easily find an eye doctor using the provider locatoron your vision benefit member homepage. Search bylocation, store hours and more — and then scheduleyour appointment.**PDF-1806-RM-646

WATCH IT ADD UPMembers who combine an eye exam and new glassessave an average of 72% off retail prices. †NEVER PAY STICKER PRICEReceive additional discounts like: †† 40% off additional pairs 20% off non-prescription sunglasses Up to 20% off anything above your frame allowanceFORM FREEWhen you stay in-network it’s easy to get an eye examand get on with your day. There’s no paperwork to fillout or forms to file. Everything is done for you.*Vision care services frequency may vary. Check yourbenefits to verify your frequency of services type.**At select in-network providers. †Savings comparisonof EyeMed versus care without vision benefits.††Discounts are not insured benefits and are available atparticipating in-network providers. Not all discounts areavailable at all provider locations. Discounts and benefitsmay vary. Check your benefits.

OUT OF NETWORK/INDEMNITYVISION SERVICES CLAIM FORMClaim Form InstructionsTo request reimbursement, please complete and signthe itemized claim form. Return the completed formand your itemized paid receipts to:Email: [email protected] Fax: 866-293-7373Mail: UniView Vision, Attn: OON Claims, P.O. Box 8504, Mason, OH 45040-7111Patient Last Name†Patient First Name†MIBirth Date (MM/DD/YYYY)† Street Address†City†Patient Member ID #State†Zip Code†Relationship to SubscriberSelfDependentDoctor or Store Name where you received service†Subscriber Last Name†Birth Date (MM/DD/YYYY)CitySubscriber First Name†MIStreet AddressStateZip CodeVision Plan NameDate of Service† (MM/DD/YYYY)Vision Plan Group #Subscriber Member ID #Required†continued1

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORMRequest for ReimbursementEnter Amount Charged.† Remember to include itemized paid receipts.†PleaseCheckLens Options: Amount(if purchased) ChargedService TypeAmountChargedLens TypeExam*92014* Single*V2100*Anti-Reflective *V2750*Refraction*92015* Bifocal*V2200*Polycarbonate *V2784*Frame*V2025* Trifocal*V2300*Scratch*V2760* Contact Lens*S0500* Progressive*V2781*Tint*V2745* Prem Prog*V278126*UV*V2755* Contact Lens Fitting *92310*Lenses Other Enter Total Amount Paid as shown on receipt,excluding sales tax†Roll and Polish *V2702* I hereby understand that without prior authorization from Blue View Vision Care LLCfor services rendered, I may be denied reimbursement for submitted vision careservices for which I am not eligible. I hereby authorize any insurance company,organization employer, ophthalmologist, optometrist and optician to release anyinformation with respect to this claim. By signing this claim form, I certify that Ihave read the applicable claim fraud warnings included with this form, and that allthe information furnished by me is true and correct.Member/Guardian/Patient Signature (not a minor)†Required†Datecontinued2

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORMNetwork Access ExceptionsWe work hard to make sure that you have access to thousands of eye doctors acrossthe nation. Whether it’s due to location or provider availability, you may need to goout-of-network to receive care.If this applies to you, please complete the following form. If not, please skipthis section.Based from your home or office location, you have the right to obtain in-network levelof benefits with an out-of-network provider when: (i) you cannot schedule a visitwithin two-weeks, (ii) you are unable to locate a participating provider within a 10mile radius in an urban-suburban area, or (iii) you are unable to locate a participatingprovider within a 20-mile radius in a rural area. You must submit a claim form toEyeMed for reimbursement.Caution, this option is not available when you choose to use an out-of-networkprovider due to (i) your preference, (ii) when your personal schedule does notpermit you to schedule an appointment with an available provider in two-weeks, (iii)or you are outside of your home or office location. Any person who, with intent todefraud or knowing that he or she is facilitating a fraud against an insurer, submitsan application or files a claim containing a false or deceptive statement is guilty ofinsurance fraud.continued3

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORMCheck the boxes that apply. I acknowledge that I fit into one or more of thefollowing criteria:I was unable to schedule a visit within two-weeks with a participating provider.Please provide the participating provider’s name, location and contactinformation in which you attempted to schedule an appointment:Provider’s NameProvider TelephoneNumber (000-000-0000)Provider Street AddressCityStateZip CodeI was unable to locate a participating provider within a 10-mile radius in anurban-suburban area.Please provide the zip code in which you were attempting to locate a provider:Zip CodeORI was unable to locate a participating provider within a 20-mile radius ina rural area.Please provide the zip code in which you were attempting to locate a provider:Zip CodeShould you fail to provide the requested information associated with thecriteria you selected above, you agree that we can process your claim asan out-of-network claim.continued4

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORMState Fraud Warning StatementsRevision date04/12/18General Fraud Warning: Any person who, with intent to defraud or knowing thathe is facilitating a fraud against an insurer, submits an application or files a claimcontaining a false or deceptive statement is guilty of insurance fraud and may besubject to fines and confinement in prison.For the states of AL, AK, AZ, AR, CA, CO, DE, DC, FL, GA, HI, ID, IN, KS, KY, LA, MA.MD, ME, MN, NC, NE, NH, NJ, NM, NY, OH, OK, OR, PA, PR, RI, TN, TX, VA, VT, WAand WV, please refer to the following fraud notices:Alabama: Any person who knowingly presents a false or fraudulent claim forpayment of loss or benefit or who knowingly presents false information in anapplication 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 deceivean insurance company files a claim containing false, incomplete, or misleadinginformation may be prosecuted under state law.Arizona: For your protection, Arizona law requires the following statement to appearon this form: Any person who knowingly presents a false or fraudulent claim forpayment of a loss is subject to criminal and civil penalties.Arkansas, Louisiana, Rhode Island, West Virginia: Any person who knowinglypresents a false or fraudulent claim for payment of loss or benefit or knowinglypresents false information in an application for insurance is guilty of a crime and maybe subject to fines and confinement in prison.California: For your protection, California law requires the following to appear on thisform: Any person who knowingly presents false or fraudulent claim for the payment ofa 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 orinformation to an insurance company for the purpose of defrauding or attempting todefraud the company. Penalties may include imprisonment, fines, denial of insuranceand civil damages. Any insurance company or agent of an insurance companywho knowingly provides false, incomplete, or misleading facts or information toa policyholder or claimant for the purpose of defrauding or attempting to defraudthe policyholder or claimant with regard to a settlement or award payable frominsurance proceeds shall be reported to the Colorado Division of Insurance within theDepartment of Regulatory Agencies.continued5