Medicare Advantage Plan Claim Form for Vision Benefits

First Name

Middle Name

Last Name

Date of Birth

Street Address

Line 2

City

State

Zip Code

SummaCare Member ID Number

Telephone Number

Are any vision hardware expenses covered under another insurance?

Yes

If “Yes,” complete the following. Name and address of company or organization:

Company / Organization Name

Company / Organization Address

Line 2

City

State

Zip Code

Receipts

PDF file required with a maximum file size of 10MB. *

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.

Signature

Date

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.

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