A Claim Form

As a Heritage Vision Plans member, you will maximize your benefits and reduce out-of-pocket costs by choosing a Heritage provider. If your plan provides out of network benefits and you choose to use an out of network provider, here are the steps to take:

Call our Customer Service Center toll free at 800.252.2053 to verify your eligibility.
Make an appointment with the provider of your choice.
When your examination is complete and you have been fitted for necessary eyeglasses or contact lenses, pay the charges in full.
Request an itemized receipt. Receipt must indicate the services provided and the amount charged for each service.
Complete all sections of this Claim Form -one form per receipt- sign, and submit the form along with your itemized receipt.

Out of network benefits are subject to the same eligibility, frequency, limitate and exclusion provisions of the plan, and are in lieu of in netwwork services.

Payment will be sent within 30 days of receiving your claim. Any missing or incomplete information may result in delay of payment. Refer to your Benefits at a Glance for reimbursement and timely filing guidelines.

For inquiries regarding your submitted claim, call our Customer Service Center toll free at 800.252.2053 or send an email to eligibility@heritagevisionplans.com.

Employer Name/Group:*

Employee Name:*

First NameLast Name

Date of Birth:*

Member ID or Last 4 of SSN:*

Phone Number:*

Please enter a valid phone number.

Address*

Street Address

Apt. or Unit #

CityState / Province

Postal / Zip Code

Name of Patient Serviced:*

First NameLast Name

Date of Birth:*

Relationship to Employee:*

SelfSpouseChildOther

Date of Service:*

Place of Service*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:*

Please enter a valid phone number.

Please select the service(s) received:

Exam Provider Type:

ODMD

Cost:

Lens Type:

Cost:

Lens Options:

Cost:

Frame Cost:

Contacts:

Elective/Cosmetic (Includes Disposable)Medically Necessary (Requires Pre-Approval)

Cost:

Contact Fit Cost:

Lasik Cost:

Receipt Upload*

Please use this field to upload a scan or PDF of your receipt.

Signature*

Date*

Payment will be sent within 30 days of receiving your claim.

Claim Form

Employee Information

Address

Patient Information

Service Information

Services Received

Signature