V10 97 Claim Form PDF Details

The V10 97 Claim Form is one of the most important documents you will use when filing a claim for benefits. This form is used to provide information about your claim and to request benefits from the VA. It is important to complete the form accurately and thoroughly so that the VA can process your claim as quickly as possible.

Here is the data in regards to the form you were seeking to fill in. It can show you how much time it takes to fill out v10 97 claim form, exactly what parts you will need to fill in, and so forth.

QuestionAnswer
Form NameV10 97 Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescentral united form, beneficiary mercer owner make, central united life vision, central united life claim forms

Form Preview Example

CENTRAL UNITED LIFE INSURANCE COMPANY

INVESTORS CONSOLIDATED INSURANCE COMPANY

CLAIM FORM

CAUTION: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.

PART A TO BE COMPLETED BY PATIENT (INSURED)IMPORTANT: ALL QUESTIONS MUST BE COMPLETED AND FORM SIGNED

 

 

 

 

 

 

 

 

 

 

 

 

Insured’s Name

 

 

 

 

Social Security No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

City or Town

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

Office Phone No.

Date of Birth

 

Marital Status

 

Sex: Male

!

 

 

 

 

 

 

 

 

 

 

Female

!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF A DEPENDENT CLAIM

 

 

 

 

 

 

 

 

 

 

Dependent’s Name

 

 

Date of Birth

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

Are you entitled to an income tax exemption for this dependent? Yes ! No !

 

 

 

 

 

If child, is he/she employed?

Yes ! No ! Name of employer

 

 

 

 

 

 

Sex: Male ! Female ! If child is over 19 years old, is child a full-time student? Yes ! No !

Name of school

Are you or your dependent entitled to benefits under: Any other vision plan? Yes ! No !

Medicare Yes ! No !

If yes, name of family member holding policy

 

 

Policy No.

 

Name and address of employer, union, association, school, etc., carrying other plan

 

 

 

 

 

 

 

Name and address of other insurance company

 

 

 

PLEASE SIGN AND DATE AUTHORIZATION

I accept this claim form and authorize release of information relating hereto. I certify the truth of all personal information contained above and that all the services listed above have been completed/delivered. I agree to be responsible for the applicable co-payment as detailed in my Group program, for any services indicated as rendered. I also agree to be responsible for any and all services which may be rendered but not eligible for coverage under my Group Program.

Patient (Parent or Subscriber Signature)

 

Date

AUTHORIZATION TO PAY BENEFITS TO PROVIDER: I hereby authorize payment directly to the Provider of the Vision Benefits for the services as described on this claim but not to exceed the scheduled amount of covered vision care expenses for these services.

Insured Person (Signature)Date

TO BE COMPLETED BY AMERICAN STATES INSURANCE

Eligibility and status approved by Central United Life/Investors Consolidated Insurance Companies

Claims Administrator

 

Date

V-10/97

COMPLETE AND RETURN

THIS FORM PROMPTLY

Central United Life Insurance Company

Investors Consolidated Insurance Company

P.O. Box 925309

Houston, TX 77292-5309

CAUTION: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.

PART B TO BE COMPLETED BY PROVIDER

 

Name

Mailing Address

 

City, State, Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Soc. Sec. No. or E.I.N.

License No.

 

 

 

 

Phone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Is exam required as condition of employment?

Yes ! No !

2. Is exam the result of occupational injury? Yes ! No !

 

 

 

3. Is exam the result of auto accident? Yes ! No !

 

4. Other accident? Yes ! No !

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Yes to 1, 2, 3 or above, give brief description and dates

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EXAMINATION

Description

Date

 

Code

Fee

Plan Allowance

Patient Responsibility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HAVE GLASSES BEEN PRESCRIBED? Yes ! No

 

 

 

 

 

 

 

 

 

 

 

!Description: ! Single Vision

! Bifocal ! Trifocal

Date

 

Code

Fee

 

Plan Allowance

Patient Responsibility

 

 

 

Bifocal/Trifocal Style:

 

 

 

 

 

 

 

 

 

 

 

 

 

Prescription:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sphere

Cylinder

 

Axis

Prism

 

Base

Base Curve

 

 

 

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIFOCAL ADD

Height

Width

PUPILLARY WIDTH:

Reading

Distance

 

 

 

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

FRAMES: Mfg. Name & Style:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HAVE CONTACT LENSES BEEN PRESCRIBED? Yes ! No

 

 

 

 

 

 

 

 

 

 

!Description: ! Hard ! Soft ! Gas Permeable

Date

 

Code

Fee

 

Plan Allowance

Patient Responsibility

 

 

!Extended Wear ! Bifocal

Prescription:

Hard or Soft Daily Wear Contact Lenses

Base Curves Lens Rx

Lens Size

2nd Curve Width

P.C. Width

2nd. Curve Radius

P.C. Radius

O.Z.

Tint

R

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

Gas Permeable or Extended Wear Contact Lenses

 

 

 

 

 

Lens Rx

Lens Size

Type or Mfg.

Add

 

Seg. Hgt.

 

R

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

BIFOCAL CCL.

 

RAM

 

 

 

 

 

Bifocal Style

 

Crescent

 

 

 

 

 

 

 

Curve Top

 

 

 

 

 

 

 

One Piece

 

 

 

 

 

Manufacturer & Style #:

The services listed above are the only services considered for possible benefits under your vision care plan. Payment of these services is subject to current eligibility on the date services are completed/delivered.

I hereby certify that the services as indicated by the date listed have been completed/delivered and that the fees submitted are the actual fees charges and intended to be collected for these services. Payment is requested in accordance with the rules and regulations of The Health Application Network

Provider Signature

Date

PROVIDER signature Required

 

V-10/97

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