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Vision Expense Reimbursement Request

  1. Per government regulations, you can’t use FSA money and be reimbursed from another health plan.
  2. Patient Information
  3. As a stand-alone plan from the Medical Plan, employees may file reimbursement claims for dependents under the age of 22 or 25 if the dependent is a full-time student. Please upload proof of student status if over the age of 22.
  4. This can be either a doctor's receipt, glasses receipt or similar document.
  5. This can be either a doctor's receipt, glasses receipt or similar document.
  6. This can be either a doctor's receipt, glasses receipt or similar document.
  7. This can be either a doctor's receipt, glasses receipt or a similar document.
  8. Leave This Blank:

  9. This field is not part of the form submission.