VISION CLAIM FORM

1. Fill out the employee/patient section below. All information must be complete.
2. Attach itemized bill(s) from the provider of service. THE RECEIPT MUST BREAK
DOWN THE CHARGES - i.e., $100 for bifocal lenses, $50 for the exam, etc.
3. Send the form and the bills to:

RCI
905 West 27th Street Attn: Marge Chapman
Scottsbluff, NE 69361 OR Fax # : (308) 635-2018
Attn : Marci Enlow

Employee Name:______________________________ Patient Name*:_________________________

(* = Use a separate form for each patient)

Employee SS#:___________________________ Patient Birthdate:___________________

Group Name: PARKVIEW MEDICAL CENTER Group #: PRKVIEW

VISION COVERAGE BENEFIT

Annual Eye Exam Covered at 85% every 12 months

Frames $100.00 allowance toward frames every 24 months

Lenses Up to $50.00 maximum on standard Single Vision Lenses,

$75.00 maximum on standard bifocals, $100.00 maximum
on standard trifocals every 24 months.

Contacts $100.00 allowance in lieu of frames/lenses. This allowance is

paid toward the provider's total cost for fitting, dispensing,
follow-up visits and materials. Contact lenses solutions are
not included in the allowance.

Please note that all expenses over and above the scheduled reimbursement become the
members' responsibility. You can use pre-tax dollars if you have a Flexible Medical
Spending Account.

QUESTIONS? Call Employee Benefits at 595-7588.