Avesis Claim Form

Vision Bene昀椀ts 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 Birthdate 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 Company 11. Name of Employer 12. Cardholder’s Status 13. Cardholder’s Birthdate Active Retired Hourly Salaried 14. Patient is covered for vision care by another plan 15. Name and Address of the Other Carrier Yes No If yes, please complete boxes 15 through 19 16. Cardholder’s Name 17. Relationship to Cardholder 18. Cardholder’s Birthdate 19. Cardholder’s S.S. # / Group # Self Child Spouse Other 20. I hereby authorize the release of any information to the Avēsis 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 bene昀椀ts 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 Contact Lenses Provider’s Address Eyeglass Lenses Single Vision Bifocal Trifocal Progressives (No Line Bifocal) Other Frame LASIK PLEASE SUBMIT THIS FORM WITH YOUR ITEMIZED RECEIPT(S) TO THE FOLLOWING Avēsis Third Party Administrators, Inc. Vision Claims Department P.O. Box 38300 Phoenix, AZ 85069-8300 . 8.31.2018 Should you have any questions or require further assistance, please call the Avēsis Service Center toll free at (800) 828-9341. REV