Maryland State Employees/retirees Routine Vision Service Form
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1
2Policy Number
ChoicePlus POS #714569
Options PPO #716450
Select EPO #716451
Maryland State Employees/Retirees Routine Vision Service Form
Section 1 Patient Information
Member Number
Employee’s Name (Last)
(First)
(M.I.)
P
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Employee Address
Patient’s Address (if Different than Employee’s)
Patient’s Relationship to Employee
o Self o Spouse o Dependent Child o Other
Patient’s Sex o Male o Female
Telephone Numbers
Patient’s Birthday
Home
Work
Section 2 Physician/Health Care Practitioner Information
N
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Practitioner must complete information below where applicable:
Description of Service
Date of Service
(Available one a year)
Line#
Mo
Day
Yr
Proc Code
Charges
1
Exam (Vision Analysis)
2
Frames (Per Frame)
3
Lenses, Single Vision
4
Lenses, Bifocal Single
5
Lenses, Bifocal Double
6
Lenses, Trifocal
7
Lenses, Aphakic (Glass)
8
Lenses, Aphakic (Plastic)
9
Lenses, Aphakic (Aspheric)
10
Contact Lenses (Cosmetic)
11
Contact Lenses (Medically Required*)
Diagnosis___________________________________________
Total Charges:_____________
*Complete below if Contact Lenses are medically required:
Date of Cataract Surgery__________________________
Practitioner Signature
Date
Visual Acuity before__________after________lenses.
Would glasses correct Visual Acuity to at least 20/70
in the better eye? o Yes o No
Section 3 Assignment of Benefits(if signed, payment will be made directly to practitioner)
I hereby authorize payment directly to the provider of services. I understand that I am financially responsible to the provider for charges not
covered by this assignment.
Signed __________________________________ Date ________________
Section 4 Authorization
I certify that the information I have given is accurate to the best of my knowledge and that I, as the Subscriber, am claiming benefits only for
the charges incurred by the patient identified above. I authorize the release of any medical information necessary to process this claim.
Subscriber Signature ________________________ Date ________ Daytime Telephone _______________
(Receipt must be attached for reimbursement)
Employee Address Correction
___________________________
___________________________
___________________________
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Parent category: Medical