Vision Benefits Claim Form PDF Details

A vision benefits claim form is a document that you fill out in order to receive benefits for vision care from your insurance company. The form typically asks for information about your eye health history, current eye health, and any vision care you have received in the past. Completing the form accurately and completely can help ensure that you receive the maximum benefit coverage possible. If you have any questions about how to complete the form or what information is required, be sure to consult with your insurance company or an optometrist.

These are some details about vision benefits claim form. This article will give you information about the form's length, completion time, and the parts you're needed to fill.

QuestionAnswer
Form NameVision Benefits Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesAVESIS, California, CARDHOLDERS, avesis claim form

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 COMPLETE THE INFORMATION BELOW ABOUT THE SERVICES RENDERED BY YOUR EYE CARE PROVIDER

 

 

 

 

 

 

 

 

 

 

DATE OF

SERVICE

 

AMOUNT

 

SERVICE

 

PAID

 

 

 

 

 

 

 

 

PROVIDER’S NAME:

 

EXAM

 

 

__________________________________

 

 

 

 

 

CONTACT LENS FITTING/EXAM

 

 

 

 

 

 

 

 

 

CONTACT LENSES

 

 

 

 

 

 

 

PROVIDER’S ADDRESS:

 

FRAME

 

 

 

 

 

 

 

 

 

 

__________________________________

 

SINGLE VISION LENSES

 

 

 

 

 

__________________________________

 

 

 

 

 

BIFOCAL LENSES

 

 

 

 

 

__________________________________

 

 

 

 

 

TRIFOCAL LENSES

 

 

__________________________________

 

 

 

 

 

PROGRESSIVE LENSES (NO LINE BIFOCAL)

 

 

 

 

 

 

 

 

 

OTHER:

 

 

 

 

 

 

 

 

PLEASE SUBMIT THIS FORM WITH YOUR ITEMIZED RECEIPT(S) 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.

REV. 4.23.12

INSURANCE FRAUD STATEMENTS

Alabama Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

Alaska Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

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.

Connecticut Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

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 knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information may be guilty of insurance fraud.

Hawaii Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

Idaho Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

Illinois Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is 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.

Iowa Residents: Any person who knowingly and with

intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

Kansas 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.

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.

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.

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.

Massachusetts 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 maybe subject to fines and confinement in prison.

Michigan Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

Minnesota Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

Mississippi Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

Missouri Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information may be guilty of insurance fraud.

Montana Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

Nebraska 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.

Nevada Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information 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.

North Dakota Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

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

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.

South Carolina Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

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

Texas 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.

Utah Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

Vermont Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information 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.

Washington 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.

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.

Wisconsin Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

Wyoming Residents: Any person who knowingly and with intent to defraud an insurer submits a written application or claim containing any materially false or misleading information is guilty of insurance fraud.

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