Transcription of Vision/Eye Care Claim Form
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Vision/Eye Care Claim Form
Vision/Eye Care Claim FormPATIENT AND SUBSCRIBER INFORMATION1. PATIENT S NAME (First, Middle Initial, Last Name)2. PATIENT S DATE OF BIRTH3. SUBSCRIBER S NAME (First, Middle Initial, Last Name) 4. PATIENT S OTHER INSURANCE INFORMATIONIS PATIENT COVERED UNDER OTHER INSURANCE? YES q NO q IF YES, NAME OF INSURANCE PATIENT COVERED UNDER MEDICARE? YES q NO qIF YES, PART A q PART B q NAME OF POLICY HOLDER (INCLUDING MEDICARE) INSURANCE OR MEDICARE NUMBER5. PATIENT S SEX MALE q FEMALE q6. SUBSCRIBER S ID NUMBER7. RELATIONSHIP TO SUBSCRIBERSELF q SPOUSE q CHILD q OTHER q8. SUBSCRIBER S GROUP NUMBER OR ENROLLMENT CODE9. WAS CONDITION DUE TO:WORK? YES q NO qAUTO ACCIDENT? YES q NO qANOTHER PARTY AT FAULT? YES q NO qIF YES, ATTACH DETAILS10. SUBSCRIBER S ADDRESS CHECK IF NEW ADDRESS qSTREETCITYSTATE ZIP11. I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND AUTHORIZE THE RELEASE OF ANY AND ALL MEDICAL INFORMATION REQUIRED TO REVIEW AND PROCESS THIS Claim .
Jul 12, 2018 · Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot ang ahente, sabihin ang wika na kailangan mo at ikokonekta ka sa isang interpreter. Español (Spanish) Atención: Este aviso contiene información sobre su cobertura de seguro. Es posible que
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