Vision Benefits Claim Form - Avesis
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2VISION BENEFITS CLAIM FORM
PLEASE BE AS THOROUGH AND ACCURATE AS POSSIBLE WHEN COMPLETING
THIS FORM. ERRORS OR OMISSIONS MAY DELAY CLAIM PAYMENTS.
TO BE COMPLETED BY THE CARDHOLDER
1.
PATIENT’S NAME (Last, First, Middle)
2.
CARDHOLDER’S GROUP #
3.
CARDHOLDER’S ID#
4.
PATIENT’S BIRTH DATE
5.
PATIENT’S SEX
6.
RELATIONSHIP TO CARDHOLDER
7.
CARDHOLDER’S NAME (Last, First, Middle)
MALE
SELF
CHILD
FEMALE
SPOUSE
OTHER
8.
CARDHOLDER’S ADDRESS (No., Street, City, State and Zip Code)
9. HOME NUMBER
WORK NUMBER
(
)
(
)
10. NAME OF INSURANCE CARRIER
11.NAME OF EMPLOYER
12. CARDHOLDER’S STATUS
13. CARDHOLDER’S BIRTH DATE
ACTIVE
RETIRED
HOURLY
SALARIED
14. PATIENT IS COVERED
15.
NAME AND ADDRESS OF THE OTHER CARRIER
IF YES, PLEASE COMPLETE
YES
FOR VISION CARE
BOXES 15 THROUGH 19
NO
BY ANOTHER PLAN
16. CARDHOLDER’S NAME
17. RELATIONSHIP TO CARDHOLDER 18. CARDHOLDER’S DATE OF BIRTH
19.
CARDHOLDER’S S.S. #/GROUP#
SELF
CHILD
SPOUSE
OTHER
20. I HEREBY AUTHORIZE THE RELEASE OF ANY INFORMATION TO AVESIS THIRD PARTY ADMINISTRATORS ACQUIRED IN THE COURSE OF MY EXAMINATION OR
TREATMENT. I CERTIFY THAT THE ABOVE INFORMATION PROVIDED BY ME IN SUPPORT OF THIS CLAIM IS COMPLETE AND CORRECT AND THAT I AM CLAIMING
BENEFITS ONLY FOR CHARGES INCURRED BY THE ABOVE NAMED PATIENT.
SIGNATURE OF CARDHOLDER ______________________________________
DATE SIGNED ______________________________________
PLEASE CHECK ALL ITEMS BELOW THAT APPLY TO THE SERVICES RENDERED BY YOUR EYE CARE PROVIDER
DATE OF SERVICE
____________
PROVIDER’S NAME
EXAM
_________________________________
CONTACT LENS FITTING/EXAM
PROVIDER’S ADDRESS
CONTACT LENSES
_________________________________
EYEGLASS LENSES
_________________________________
SINGLE VISION
_________________________________
BIFOCAL
_________________________________
TRIFOCAL
PROGRESSIVE (NO LINE BIFOCAL)
OTHER
________________
FRAME
PLEASE SUBMIT THIS FORM WITH YOUR ITEMIZED RECEIPT(S) OR SUPERBILL WITH A $0 BALANCE CONFIRMING
CHARGES PAID IN FULL TO THE FOLLOWING
Avesis Third Party Administrators, Inc.
Vision Claims Department
P.O. Box 7777
Phoenix, AZ 85011-7777
Should you have any questions or require further assistance, please call the Avesis Service Center toll free at (800) 828-9341.
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