The Centers for Medicare and Medicaid Services (CMS) 1500 claim form is the acceptable standard for paper billing of professional medical services. This claim form must be signed.Mail. To submit your claim via these measures, please complete a Claim for Damages form (PDF) and return it to us along with all supporting documentation. When you visit an out-of-network provider, you will need to submit your own claim to Anthem Blue View Vision for reimbursement. This form is used when seeking reimbursement for non-participating providers. STEP 1: Fill out the attached forms (Claim Affirmation Form and Claim for Money. Held). To calculate your premium payments, use the attached Schedule of Rates and worksheet. You'll need to include a completed FMP Claim Cover Sheet (VA Form 107959f2) and your supporting documents. Medi-Cal is California's Medicaid program. Employee reimbursement claim.