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  3. Member ID Number
  4. Member’s Name
  5. Mailing Address
  6. Section
  7. Phone
  8. Email
  10. Does the patient have other insurance besides Select Health?
  12. Select the eyewear that requires reimbursement
  13. Date of Cataract Surgery for Right Eye
  14. Date of Cataract Surgery for Right Eye
  15. Select your diagnosed vision impairment
  17. Billed Amount
  18. Section

Eyewear Reimbursement Form

Medicare Advantage members, fill and submit this form if you’d like to request a reimbursement for purchased eyewear or cataract surgery. 

 

Member & Patient Information
Other Insurance Information
Claim INformation
Receipt & Documentation

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