Medicare Advantage Plan Claim Form for Vision Benefits

AUTHORIZATION TO RELEASE INFORMATION – I hereby authorize any physician, hospital, pharmacy, insurance company, employer, third party payer or organization to release any information regarding the history, treatment or benefits payable concerning this claim to SummaCare. I certify that the information submitted by me is true. I understand that falsifying a claim can lead to disciplinary action, including discharge.

By typing my name and providing today's date above, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Any person who knowingly intends to defraud an insurance company, and files a statement containing any materially false information or conceals information concerning any fact, commits a fraudulent insurance act, which is a crime.

You should receive your reimbursement within 30 days of submitting this form. SummaCare is an HMO and HMO-POS plan with a Medicare contract. Enrollment in SummaCare depends on contract renewal. If you have questions about this form, please call Member Services at 330.996.8885 or (toll free) 800.996.6250 (TTY 711). From October 1 through March 31, a representative is available to take your call 8 a.m. to 8 p.m., seven days a week. From April 1 through September 30, a representative is available to take your call 8 a.m. to 8 p.m., Monday through Friday. A submission is not considered complete until all required fields are correctly filled out and a valid attachment has been successfully uploaded.

If you prefer to mail your form, please send the completed form and itemized bill(s) to:
SummaCare Claims, PO Box 3620, Akron, Ohio 44309-3620
H3660_SC2608_C 07062026