Vision Reimbursement – Staff Gateway Creating Communcations

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Submitted Date

Member / Employee is the Patient

Employee ID Number(Required)

Division

Social Security Number: (last 4)

Please enter a number from 0 to 9999.

Last 4 of Social Security Number

Date of Birth:

Employee Name(Required)

First Last

Employee Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relation to Member(Required)

Social Security Number: (last 4)

Please enter a number from 0 to 9999.

Last 4 of Social Security Number

Date of Birth

Patient Name(Required)

First Last

Patient Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Service(Required)

Lens Type

Provider

Exam Cost

Frames Cost

Lenses Cost

Lens tints or coatings Cost

Contact Lens Exam / Fitting Evaluation Cost

Contacts Cost

Total

Additional Comments

Please upload Receipts.

Signature

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Approved Check Amount

Check #

Date