INSTRUCTIONS: SOUTHLAND VISION CLAIM FORM
Alabama public employees who are enrolled with Southland Benefit Solutions health insurance use the vision claim form discussed in this article to file for coverage for a vision health appointment. This document can be obtained from the website of Southland Benefit.
Southland Vision Claim Form Step 1: The top half of the form is to be completed by you. In box 1, indicate with a check mark whether you are enrolled with Medicare, Medicaid, a group health plan or other. Give the number of your plan in box 1a.
Southland Vision Claim Form Step 2: Enter the patient's name in box 2. Enter the last name first, followed by the first name and middle initial.
Southland Vision Claim Form Step 3: Enter the patient's birth date in box 3.
Southland Vision Claim Form Step 4: Enter the insured's name in box 4.
Southland Vision Claim Form Step 5: Enter the patient's address in box 5.
Southland Vision Claim Form Step 6: Indicate the patient's relationship to the insured with a checkmark in box 6.
Southland Vision Claim Form Step 7: Enter the insured's street address, city, state, zip code and telephone number including area code in box 7.
Southland Vision Claim Form Step 8: Indicate the patient's status with a checkmark in box 8. Choose from "single," "married," "other," "employed," "full-time student" and "part-time student" as appropriate.
Southland Vision Claim Form Step 9: In boxes 10 through 10d, give the insured's group policy or FECA number, employer's or school name, insurance plan or program name, and indicate if there is another health benefit plan. If so, complete boxes 9 through 9d.
Southland Vision Claim Form Step 10: The patient or an authorized person should sign box 11.
Southland Vision Claim Form Step 11: The insured or an authorized person should sign box 12.
Southland Vision Claim Form Step 12: The remainder of the form should be submitted to the office of the vision physician or supplier in question. This office will be responsible for completing and submitting the form.
Southland Vision Claim Form Step 13: This form must be submitted by the physician or supplier to Southland within 365 days of the date of service. The address to which this form should be submitted can be found at the top of the page.
