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Request Application Packet

Dr. Name:*
Phone:*
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email:
Where did you hear about us?:*

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Name*
First Last
Email*
Phone*

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Out of Network Reimbursement Request

Insured Member Identification Number*
Insured Member's Full Name*
Insured Daytime Phone Number*
Insured Address
Patient Name*
Date of Service*
MM slash DD slash YYYY
Place of Service - Provider Name*
Provider Phone Number*
Provider Address
Itemized Price(s) Paid
Examination*
Dilation*
Contact Fitting*
Lenses*
Scratch Coating*
UV Coating*
Coatings and Extras
Frame*
Contacts*
File upload / Picture of Receipt
Drop files here or

Max. file size: 50 MB.
Please submit completed form & itemized receipt to:
Opticare Vision Services
1901 West Parkway Blvd
Salt Lake City, UT 84119
(801) 869-2020
Service@opticarevisionservices.com
Questions or Comments :
(800) 363-0950
www.opticarevisionservices.com

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