Order a Vision Claim Form

Use the form below to order a precertified MedBen VisionPlus claim form. When your eligibility has been confirmed, MedBen will mail the precertified claim form directly to you within one business day. (Note: Visiting a provider without a claim form may result in reduced benefits. To ensure you receive the highest level of benefits for which you are eligible, please request your form at least three days prior to your appointment.)

If you have questions in regard to ordering a claim form, please contact MedBen Customer Service by e-mailing customerservice@visplus.com or calling toll-free (800) 252-3447.

If you have any problems in sending this form, please contact the site's webmaster at chuckj@medben.com.

Person for whom form is being requested:
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