Claim forms are not needed if you use a “Select” in-network EyeMed provider. The in-network provider will apply any discounts and plan reimbursement provisions at the time of rendering the service. The provider will then bill you the balance.
Should you elect to use an out-of-network (“OON”) provider for services, then you can download the EyeMed Out-of-Network Vision Claim form to submit your claim. You can also contact SAMBA directly at 1-800-638-6589 or firstname.lastname@example.org to mail you a form.
Mail your OON claim form, along with an itemized receipt, to:
First American Administrators, Inc.
Attn: OON Claims
P. O. Box 8504
Mason, OH 45040-7111