Forms and Documents
Out-of-Network Claim Form
When there is no provider available:
You have the right to obtain in-network level of benefits with an out-of-network provider when: (i) you cannot schedule a visit within two-weeks, (ii) you are unable to locate a participating provider within a 10-mile radius in an urban-suburban area, or (iii) you are unable to locate a participating provider within a 20-mile radius in a rural area. You must submit a claim form to EyeMed for reimbursement. Complete the OON claim form, which includes additional information and requirements.
Caution, this option is not available when you choose to use an out-of-network provider due to (i) your preference or (ii) when your personal schedule does not permit you to schedule an appointment with an available provider in two-weeks. Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Don't see your preferred doctor? Ask him or her to complete our online form at www.eyemedinfocus.com/join. All doctors must accept our terms and conditions and complete credentialing before providing service to EyeMed members.