Vision Benefits Claim Form PDF Details

Navigating the terrain of insurance claims can often feel like deciphering an ancient script. Among such forms, the Vision Benefits Claim Form emerges as a critical document for those aiming to secure reimbursements for vision care expenses. This form mandates a meticulous level of accuracy and thoroughness from the cardholder, highlighting the importance of providing correct and complete information to ensure the smooth processing of claims. Essential fields include patient and cardholder details, such as names, identification numbers, and relationships, alongside specifics about the insurance carrier and employer, delineating the pathway to ascertain coverage eligibility. Furthermore, the form opens a window into the detailed universe of vision care, demanding information about the services rendered—ranging from exams to eyewear. Also crucial is the authorization for information release, underpinning the claim's legitimacy, and a declaration ensuring that the information provided is truthful and claims are made solely for incurred charges. Augmenting the form are stark fraud warnings across various states, underscoring the legal implications of submitting fraudulent claims, thereby weaving a tapestry of accountability and precision. Thus, this form not only facilitates the reimbursement process but also diligently guards against insurance fraud, illuminating its multifaceted role in the landscape of vision care insurance.

QuestionAnswer
Form NameVision Benefits Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesclaimant, avesis forms, avesis android app, Arizona

Form Preview Example

VISION 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

… YES

IF YES, PLEASE COMPLETE

 

15. NAME AND ADDRESS OF THE OTHER CARRIER

 

 

FOR VISION CARE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

… NO

BOXES 15 THROUGH 19

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 38300

Phoenix, AZ 85069-3800

Should you have any questions or require further assistance, please call the Avesis Service Center toll free at (800) 828-9341.

REV. 11.2.2015

INSURANCE FRAUD STATEMENTS

FRAUD NOTICE: For the states of AL, AZ, AR, CA, CO, DE, DC, FL, GA, IN, KS, KY, LA, MD, ME, NC, NE, NJ, NM, OK, OR, PA, RI, TN, TX, VA, VT, and WV, please refer to the following fraud notices:

Alabama Residents: Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof.

Arizona Residents: For your protection, Arizona law requires the following statement to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Arkansas Residents: Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

California Residents: For your protection, California

law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Delaware Residents: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

District of Columbia Residents: 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 a claim was provided by the applicant.

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

Georgia Residents: Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Indiana Residents: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.

Kansas Residents: Any person who with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud as determined by a court of law.

Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Louisiana Residents: Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Maryland Residents: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Maine Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Nebraska Residents: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a materially false or deceptive statement is guilty of insurance fraud.

New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New Mexico Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

North Carolina Residents: Any person with the intent to injure, defraud, or deceive an insurer or insurance claimant is guilty of a crime (Class H felony) which may subject the person to criminal and civil penalties.

Oklahoma Residents: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Oregon Residents: Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines and denial of insurance benefits.

Texas Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Vermont Residents: Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Virginia Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

West Virginia Residents: Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

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writing insurer part 1

Remember to note your data inside the area PLEASE CHECK ALL ITEMS BELOW THAT, DATE OF SERVICE, PROVIDERS NAME, cid EXAM, cid CONTACT LENS FITTINGEXAM, PROVIDERS ADDRESS, cid CONTACT LENSES, cid EYEGLASS LENSES, cid SINGLE VISION cid BIFOCAL cid, cid FRAME, PLEASE SUBMIT THIS FORM WITH YOUR, and Avesis Third Party Administrators.

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