Form Gc-14424 - Aetna Vision Providers Statement

Vision Provider's Statement

Aetna Global Benefits

®

Coverage underwritten by Aetna Life Insurance

Company and Aetna Life & Casualty (Bermuda) Ltd.

• This form should be completed and submitted if an itemized bill is not

• Dispenser NOTE: If you have not provided fully itemized bills to the

provided by the vision supply dispenser to accompany the Claim Form

patient, you should complete items 19-28 of this form, attach it to all bills

(GR-68069) or if the vision claims being submitted for consideration are

and a completed Claim Form (GR-68069), and mail them to the address

charges incurred from a physician. The Summary of Reimbursement

on the back of the member's insurance Identification Card or Aetna Global

section of the Vision Benefit Request form will identify the party to whom

Benefits,

benefit payments should be made payable/sent.

P.O. Box 30258, Tampa, FL, 33630-3258, U.S.A.

• Fully itemized lab bills and receipts from a vision supply dispenser should

• Employee completes Sections 1-2.

include: Patient's name and relationship to employee, Provider/Dispenser

• Doctor completes Sections 3 - 18.

Name/address/telephone number, type of lense dispensed (i.e. contacts, single

• Dispenser completes Sections 19 - 28.

vision, bifocal, etc), type of frame (wire, plastic, etc), date the appliance (i.e.

glasses) was delivered to the patient, amount charged for each service/supply.

1. Employee's Name

2. Employee's Social Security/I.D. Number

3. Patient's Name

4. Patient's Birthdate (mm/dd/yyyy)

5. Doctor's Name & Address (include zip code)

6. Telephone Number

7. If applicable, enter the taxpayer identifying number to be used for U.S. 1099

(

)

reporting purposes. You are required under authority of U.S. law to furnish

your taxpayer identifying number.

8. Title

9. Examination Date(s) (mm/dd/yyyy)

M.D.

D.O.

O.D.

10. Has Cataract surgery

11. Can visual acuity be restored to 20/70 in

12. Does patient require a prescription change

been performed?

better eye with conventional eyeglasses?

at this time?

No

Yes

No

Yes

No

Yes

13. Diagnostic Code(s)

;

;

;

;

14. Indicate diagnosis or nature of disease or injury or vision disorder, indicate procedure code numbers

15. Visual acuity corrected to

16. Doctor's Prescription

17. Professional Service

Amount

Sphere

Cylinder

Axis

Prism

Base

Examination Charge

$

|

R.E.

|

!

!

Sales Tax (if any)

$

|

L.E.

|

!

!

Total

$

|

Reading Add

R.E.

+ !

L.E.

+ !

Amount Paid by Patient

$

|

18. I hereby certify that the procedures as indicated by date have been completed and that the fees submitted are the actual fees I have charged this patient and intend to accept for those procedures.

Doctor's Signature

Date

Note: In lieu of dispenser completing this section a laboratory bill can be attached. Dispenser must sign this form, enter amount paid by

patient.

19. Dispenser's Name & Address (include zip code)

20. Telephone Number

21. If applicable, enter the taxpayer identifying number to be used for U.S.

(

)

1099 reporting purposes. You are required under authority of U.S. law to

furnish your taxpayer identifying number.

22. Title

Optician

Optometrist

Ophthalmologist

23. Date (mm/dd/yyyy)

24. Material Supplied

Order

Glass

Plastic

Oversized

Tint #

Delivery

Pair

1/2 Pair

Other

25. Type of lenses dispensed

26. If contact lenses, please complete

27. Professional Service

Amount

None

Therapeutic

Lens Charge

$

|

Single

Non-Therapeutic

Frame Charge

$

|

Bifocal

Hard Lenses

Optional

Lens

$

|

Trifocal

Soft Lenses

Frame

$

|

Lenticular

Disp. Fee

Lens

$

|

Contacts

Frame

$

|

Sunglasses

Sales Tax (if any)

$

|

Other (specify below)

Total

$

|

Amount Paid By

$

|

Patient

28. I hereby certify that I have performed the services as indicated hereon and that the fees submitted are the actual fees I have charged this patient and intend to accept for those procedures.

Dispenser's Signature

Date

Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment

and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to claim was provided by the applicant. California Residents: For your

protection, California law requires notice of the following: Any person who knowingly and with intent to defraud or deceive any insurance company files a statement of claim

containing any materially false, incomplete or misleading information is guilty of a crime and may be subject to fines, confinement in a state prison and substantial civil

penalties.

Colorado Residents: An insurer or agent who knowingly provides false or misleading information to defraud a claimant regarding insurance proceeds must be

reported to the Insurance Division.

Please Retain A Copy For Your Records

GC-14424 (11-04) A-POD