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Claiming reimbursement for your insurance

Please use the form below to apply your insurance benefits when you buy glasses or contacts online at

Download the form 


  1. To request reimbursement, complete this form and print (complete using blue or black ink).

  2. Enclose a legible copy of your itemized receipt(s).

  3. Send this signed form with receipts to your vision insurance company.

Keep a copy for your records. Your insurance company will notify you if it needs additional information from you.

Note: Not all insurance plans have out-of-network benefits. Contact your insurance company to check benefits available to you from

out-of-network providers.

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