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Any person who knowingly presents false or fraudulent claim for the payment of a loss is. Web out of network/indemnity vision services claim form claim form instructions to request reimbursement, please complete and sign the itemized claim. Return the completed form and copies of your itemized paid receipts to: You can now submit your form online or by mail:
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If the paid receipt is not in us dollars, please identify the currency in which the receipt was paid. Web eyemed out of network claim form. If the paid receipt is not in us dollars, please identify the currency in which the receipt was paid. For your protection, california law requires the following to appear on this form:
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