INSTRUCTIONS: SOUTHLAND VISION CLAIM FORM

Alabama public employees file the form discussed in this article to obtain reimbursement for vision treatment. This form is processed by Southland Benefit Solutions, which manages health care for the state of Alabama. The document can be found on the website of the Retirement Systems of Alabama.

Southland Vision Claim Form Step 1: In box 1, indicate the type of coverage you have with a check mark. In box 1a, enter your insurance identification number.

Southland Vision Claim Form Step 2: Enter the patient name in box 2, their birth date and gender in box 3, and the last name of the insured in box 4.

Southland Vision Claim Form Step 3: Enter the patient's address in box 5, indicate the patient's relationship to the insured in box 6, and give the insured's address in box 7.

Southland Vision Claim Form Step 4: In box 8, indicate with the check marks whether the patient is single, married or other, as well as whether the patient is employed, or a part-time or full-time patient.

Southland Vision Claim Form Step 5: Skip to box 10 and enter the insured's policy group or FECA number. Enter the insured's date of birth in box 10a, their employer or school name in box 10b and their insurance plan or program name in box 10c. If you have another health benefit plan, return to boxes 9 through 9d and complete them.

Southland Vision Claim Form Step 6: Enter the insured's name in box 9, their policy or group number in box 9a, their date of birth and gender in box 9b, their employer or school name in box 9c, and their insurance plan or program name in box 9d.

Southland Vision Claim Form Step 7: The patient or an authorized person should sign and date box 11.

Southland Vision Claim Form Step 8: The insured or an authorized person should sign box 12.

Southland Vision Claim Form Step 9: The remainder of the form should be completed by the supervising physician. Your vision prescriptions will be entered, along with a diagnosis of your illness or injury, a detailed itemization of all services provided, and identifying information about the doctor and their place of business. The physician should sign and date the bottom of the document.