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Routine Vision Reimbursement Form
Please complete this form and attach an itemized, paid receipt. Submit your request for reimbursement to:

NFP Benefit Alliance
5810 Southwyck Blvd., Suite 200
Toledo, OH 43614
Or fax:
419-244-5743

Your routine vision benefit allows for you and each eligible dependent on your contract to be reimbursed for frames, lenses, or contact lenses, to a total of $100.00 every 24 months. Further questions about your vision benefits can be directed to NFP Benefit
Alliance at 419-244-0135.

OR Fill out the form below:
Policy Holder's Name:
Field is required!
Field is required!
ID Number:
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Field is required!
Patient's Name:
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Field is required!
Upload your itemized paid receipt...
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Field is required!

We have a team of expert professionals that possesses relevant experience in this domain. Our professionals work in close coordination with the clients and carefully analyze their specific requirements.

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