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

PLEASE SUBMIT THIS FORM WITH YOUR ITEMIZED RECEIPT(S) TO THE FOLLOWING FRAUD NOTICE: For the states of AL, AZ, AR, CA, CO, DE, DC, FL, GA, Maine, Tennessee, Washington: It is a crime to knowingly provide IN, KS, KY, LA, MD, ME, NC, NE, NJ, NM, OK, OR, PA, RI, TN, TX, VA, false, incomplete or misleading information to an insurance company VT, WA and WV, please refer to the following fraud notices: for the purpose of defrauding the company. Penalties may include Alabama: Any person who knowingly presents a false or fraudulent imprisonment, 昀椀nes or a denial of insurance bene昀椀ts. claim for payment of loss or bene昀椀t or who knowingly presents false Nebraska: Any person who, with intent to defraud or knowing that he or information in an application for insurance is guilty of a crime and may be she is facilitating a fraud against an insurer, submits an application or 昀椀les subject to restitution, 昀椀nes or con昀椀nement in prison, or any combination a claim containing false, incomplete or misleading information is guilty of thereof. insurance fraud. Arizona: For your protection, Arizona law requires the following New Jersey: Any person who knowingly 昀椀les a statement of claim statement to appear on this form: Any person who knowingly presents a containing any false or misleading information is subject to criminal and false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. civil penalties. New Mexico: Any person who knowingly presents a false or fraudulent Arkansas, Louisiana, Rhode Island, West Virginia: Any person who claim for payment of a loss or bene昀椀t or knowingly presents false knowingly presents a false or fraudulent claim for payment of loss information in an application for insurance is guilty of a crime and may be or bene昀椀t or knowingly presents false information in an application subject to civil 昀椀nes and criminal penalties. for insurance is guilty of a crime and may be subject to 昀椀nes and North Carolina: Any person with the intent to injure, defraud, or deceive con昀椀nement in prison. an insurer or insurance claimant is guilty of a crime (Class H felony) which California: For your protection, California law requires the following may subject the person to criminal and civil penalties. to appear on this form: Any person who knowingly presents false or Oklahoma: WARNING: Any person who knowingly, and with intent to fraudulent claim for the payment of a loss is guilty of a crime and may be injure, defraud or deceive any insurer, makes any claim for the proceeds subject to 昀椀nes and con昀椀nement in state prison. of an insurance policy containing any false, incomplete or misleading Colorado: It is unlawful to knowingly provide false, incomplete, or information is guilty of a felony. misleading facts or information to an insurance company for the purpose Pennsylvania: Any person who knowingly and with intent to defraud of defrauding or attempting to defraud the company. Penalties may any insurance company or other person 昀椀les an application for insurance include imprisonment, 昀椀nes, denial of insurance and civil damages. Any or statement of claim containing any materially false information or insurance company or agent of an insurance company who knowingly conceals, for the purpose of misleading, information concerning any fact provides false, incomplete, or misleading facts or information to a material thereto commits a fraudulent insurance act, which is a crime and policyholder or claimant for the purpose of defrauding or attempting to subjects such person to criminal and civil penalties. defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Texas: Any person who knowingly presents a false or fraudulent claim Division of Insurance within the Department of Regulatory Agencies. for payment of a loss is guilty of a crime and may be subject to 昀椀nes and Delaware: Any person who knowingly, and with intent to injure, defraud con昀椀nement in state prison. or deceive any insurer, 昀椀les a statement of claim containing any false, Virginia: It is a crime to knowingly provide false, incomplete or incomplete or misleading information is guilty of a felony. misleading information to an insurance company for the purpose of District of Columbia: WARNING: It is a crime to provide false or defrauding the company. misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or 昀椀nes. In addition, an insurer may deny insurance bene昀椀ts if false information materially related to a claim was provided by the applicant. Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer 昀椀les a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Georgia, Oregon, Vermont: Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or 昀椀les a claim containing a false or deceptive statement may be guilty of insurance fraud. Indiana: A person who knowingly and with intent to defraud an insurer 昀椀les a statement of claim containing any false, incomplete, or misleading information commits a felony. Kansas: Any person who with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or 昀椀les a claim containing a false or deceptive statement may be guilty of insurance fraud as determined by a court of law. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person 昀椀les 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. Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or bene昀椀t or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to 昀椀nes and con昀椀nement in prison.