Request a Provider

Unable to locate your provider on the provider directory? Fill out the form below:
Select Your Network:
Direct
Expanded
Standard

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Provider Information

If this is not applicable, please enter NA in fields below.

Signature / Contact Info

Thank you for submitting your reimbursement. Please allow 1-2 weeks to process. If you submitted wrong information, or have any questions, please reach out to Vision@samerahealth.com.
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Policy Information

Patient Information

Provider Information

If this is not applicable, please enter NA in fields below.

Signature / Contact Info

Thank you for submitting your provider add Request. Please allow up to 60 days to complete. If you submitted wrong information, or have any questions, please reach out to info@samerahealth.com.
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Text Link

Policy Information

Patient Information

Provider Information

If this is not applicable, please enter NA in fields below.

Signature / Contact Info

Thank you for submitting your reimbursement. Please allow 1-2 weeks to process. If you submitted wrong information, or have any questions, please reach out to Vision@samerahealth.com.
Home
Oops! Something went wrong while submitting the form.