OUT-OF-NETWORK PAPER FORMS

Manual Filing for Out-of-Network Reimbursement

Visit an eye care professional and receive services and/or materials. You will be responsible for paying the full amount for these services and/or materials at time of service.

Select your appropriate state on the right to download and complete the Out of Network Request for Payment form.

Within 12 months from your date of service, send in the completed form along with itemized receipts to:

Vision Care Direct
Attention: Out of Network Requests
3515 W Central Ave
Wichita, KS 67203