• All sections must be completed to ensure quicker processing
• Be sure to have the following information ready:
  • Your name, date of birth, Social Security number (SSN) and address
  • Claimant’s name, date of birth, SSN (if other than primary insured)
  • Treating physician’s information (must be a optometrist or ophthalmologist)
  • Date of vision exam
  • Bills or proof of treatment for eye exams, vision correction, eyeglasses, and other related out-of-pocket expenses

Then, before you know it, you’ll start receiving the benefits you need in less time than filing by paper

For a paper form, download, print and fax the completed document to 1-800-880-9325 or mail to P.O. Box 100195, Columbia, SC 29202-3195.

Vision claim form