Optical Form PDF Details

In the rapidly evolving landscape of healthcare benefits, the Optical form serves as a vital document for individuals seeking to understand and utilize their vision-related benefits effectively. Issued by Administrative Services Only, Inc., this form is designed specifically for the New York State Nurses Association (NYSNA) Welfare Plan, catering to the needs of full-time and part-time nurses and their dependents within New York City. The form becomes operative from April 1, 2009, signifying a structured approach toward facilitating optical benefits that cover a wide range of services, from exams to the dispensation of frames and lenses. It outlines the necessary patient and member/employee information required for spouses and dependents, including detailed sections for provider details, thereby encapsulating a comprehensive claim process. The inclusion of specific conditions such as accidents, injuries, or occupational hazards reflects a nuanced understanding of the various scenarios that might necessitate optical care. Moreover, the explicit mention of eligibility criteria for benefit claims, alongside the procedural steps for submitting a claim—including the authorization to release information and assignment of benefits—underscores the administrative diligence essential for transparent and equitable access to healthcare benefits. This form not only serves as a procedural guide but also highlights the organizational commitment to supporting healthcare professionals and their families by addressing their optical health needs.

QuestionAnswer
Form NameOptical Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesnysna optical form, nysna optical benefit form, nysna vision plan, nysna forms

Form Preview Example

RETURNTO:

Administrative Services Only, Inc. P.O. Box 9005

Department 136 Lynbrook, NY 11563 1-888-692-7671 www.asonet.com

NYSNA WELFARE PLAN

FOR NYC EMPLOYED REGISTERED PROFESSIONAL NURSES

OPTICAL FORM

Effective 4/1/09 Optical Benefits available for Full-Time Nurses and their dependents and Part-Time Nurses Member Only, once every 24 months.

PATIENT INFORMATION (REQUIRED ON CLAIMS FOR SPOUSES AND DEPENDENTS)

Patient Name

Birthdate

RelationshiptoMember

Spouse

Child

Full Time College Student School

Yes

No

MEMBER/EMPLOYEE INFORMATION

MemberName

 

Birth date

 

SocialSecurity#

 

 

 

 

 

 

 

Street Address

City

State

Zip

Telephone#

 

 

 

 

 

(

)

 

 

 

 

 

 

 

Member'sSchoolorWorkLocation

 

WorkTelephone#

 

 

 

 

 

 

 

 

 

 

 

SPOUSE INFORMATION

Spouse'sName(Print)

 

 

Birthdate

 

 

SocialSecurity#

 

 

 

 

 

 

IsspousecoveredbyanotherBenefitsPlan?

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name,Address,Telephone#ofSpousesEmployer

 

 

 

 

 

 

 

 

 

 

 

 

 

NameofBenefitPlan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ARE ANY OTHER OPTICAL BENEFITS AVAILABLE FOR THIS PATIENT?

 

YES

NO

 

 

 

 

 

 

IS THIS AN HMO PLAN?

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER INFORMATION (EXAMINER)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider's Name (Print)

 

 

License #

 

 

Telephone #

 

 

 

 

 

 

Taxpayer ID#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

StreetAddress

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

 

ZipCode

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IS THIS CLAIM THE RESULT OF:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accident or Injury?

Yes

 

No

 

 

 

Occupational Injury? Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certification of Examiner: I have examined the above named patient and have found the following vision defects:

 

Exam Fee($)

 

 

Signature of Examiner

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER INFORMATION (DISPENSER OF FRAMES AND LENSES)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider's Name (Print)

 

 

License #

 

 

Telephone #

 

 

 

 

 

 

Taxpayer ID#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

City

 

 

 

 

 

 

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IS THIS CLAIM THE RESULT OF: Accident or Injury?

Yes

 

No

 

 

 

Occupational Injury? Yes

No

 

 

 

 

WAS THE EXAMINATION REQUIRED BY:

AN EMPLOYER AS A CONDITION OF EMPLOYMENT? Yes

 

No

 

 

 

 

BY A GOVERNMENT BODY? Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SERVICE

 

FEE($)

 

DATE

FOR OFFICE USE

 

 

 

You may check on eligibility for this

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

benefit 24 hours a day, 7 days a week

 

 

FRAMES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

by phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LENSES Single Vision

 

 

 

 

 

 

 

 

 

 

 

 

516-396-5561

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

800-537-1238 ex 5561

 

 

 

Bifocal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trifocal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

thru the internet:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

www.asonet.com

 

 

 

Lenticular

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Only claims with a service date on or after

 

 

Contact Lenses

 

 

 

 

 

 

 

 

 

 

 

 

 

4/1/09 will be honored. Benefits are

limited

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

to once every 24 months

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Dispenser

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

AUTHORIZATIONTORELEASEINFORMATION

I hereby authorize any insurance company, prepayment organization, hospital, physician, or its designated agent to release all information with respect to myself or any of my dependents which may have a bearing on the benefits payable under this or any other plan providing benefits or services. A photocopy of this authorization, when duly executed, shall serve in the same capacity as the original. I certify that the information submitted by me in support of this claim is true and correct. Authorization must be signed or payment will not be made. I understand that I am financially responsible for charges not payable by the Fund.

Signed (Patient, or Parent if Minor)DATE

ASSIGNMENT OF BENEFITS: I hereby authorize payment of the benefits (otherwise payable to me) directly to the above named physician. I understand I am financially responsible for charges not covered by this authorization.

Signed (Member)

 

DATE

 

BENEFITSCANNOTBEASSIGNEDTONON-PARTICIPATINGPROVIDERS.

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1. The nysna vision benefits will require certain information to be entered. Ensure the next blank fields are complete:

Learn how to complete csa optical form stage 1

2. Right after completing the previous step, head on to the subsequent step and fill in all required particulars in these blanks - Certification of Examiner I have, Signature of Examiner, Date, PROVIDER INFORMATION DISPENSER OF, License, Telephone, Taxpayer ID, Street Address, City, State, Zip Code, IS THIS CLAIM THE RESULT OF, Occupational Injury Yes, BY A GOVERNMENT BODY Yes, and SERVICE.

Step no. 2 of filling in csa optical form

People generally make some errors while filling in Occupational Injury Yes in this section. Don't forget to double-check what you enter here.

3. Completing AUTHORIZATION TO RELEASE, Signed Patient or Parent if Minor, DATE, ASSIGNMENT OF BENEFITS I hereby, Signed Member, DATE, and BENEFITS CANNOT BE ASSIGNED TO is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Writing section 3 in csa optical form

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