Please use the form below to apply your insurance benefits when you buy glasses or contacts online at DesignerOptics.com
INSTRUCTIONS
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To request reimbursement, complete this form and print (complete using blue or black ink).
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Enclose a legible copy of your itemized receipt(s).
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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.
