Blue View Vision Out of Network Vision Services …

Blue View Vision a4. Out of Network Vision Services claim form claim form instructions Most Blue View Vision Care plans allow members the choice to visit an in- Network or out-of- Network Vision care provider. You only need to complete this form ifyo~C3~~visitingaprovider that is not a participating provider in the Blue. View. Vision n !~ork.. ,~anlic!f!'~t.>ouf;..dfi;n'ttM9fk benefits,so pleB;se 9 Qnsultyou r memper .bene'its '!flttJ~mationto (!iris .'at/Pfl ofSIPlioes andlormaterla/s from nQn;'participating providers.. If you choose an out-of- Network provider, please complete the following steps prior to submitting the claim form to Blue View Vision . Any missing or incomplete information may result in delay of payment or the form being returned. Please complete and send this form to Blue View Vision within one (1) year from the original date of service at the out-of- Network provider's office.)

Blue View . Vision. a4 . Out of Network Vision Services Claim Form . Claim Form Instructions . Most Blue View Vision Care plans allow members the choice to visit an in-network or out-of-network

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