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  • Avesiscommaricopa Form

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NAME (Last, First, Middle) 4. PATIENT S BIRTH DATE 8. 2. CARDHOLDER S GROUP # 5. PATIENT S SEX 6. MALE FEMALE CARDHOLDER S ADDRESS (No., Street, City, State and Zip Code) 10. NAME OF INSURANCE CARRIER 14. PATIENT IS COVERED FOR VISION CARE BY ANOTHER PLAN RELATIONSHIP TO CARDHOLDER SELF CHILD SPOUSE OTHER 11.NAME OF EMPLOYER YES NO IF YES, PLEASE COMPLETE BOXES 15 THROUGH 19 3. 7. CARDHOLDER S ID# CARDHOLDER S NAME (Last, First, Middle) 9. HOME NUMBER ( ) WORK NUMB.

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Related content

Vision | Retirees | Benefits Services Division...
The Avesis Advantage Program is voluntary insurance where you pay the entire premium. ·...
Learn more
VISION BENEFITS CLAIM FORM
PLEASE SUBMIT THIS FORM WITH YOUR ITEMIZED RECEIPT(S) TO THE FOLLOWING. Avesis Third Party...
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The Avesis Advantage Program is voluntary insurance where you pay the entire premium. It provides yearly coverage for a vision exam, glasses or contact lenses, extensive provider access throughout the state, and a $750 allowance for LASIK. You can also receive unlimited discounts on additional optical purchases.

Participating Retailers Avēsis participates with many of the nation's top retailers such as Walmart, Sam's Club, and . Materials are covered up to the plan allowances depending on the plan selection, with any overage being a member responsibility.

The Avesis plans provide covered members with a complete vision examination, a pair of spectacle lenses, and a frame. If the member elects to receive contact lenses in place of spectacle lenses and frames, Avesis will provide a generous allowance of $110 or $130 depending on the plan selected.

How do I get an ID card? If you are in need of vision care services and your Avesis ID Card has not yet arrived in the mail, you can print off a temporary ID card. Simply log in as a member, select "Print ID Card," and print!

Since 1978, Avēsis has been providing vision, dental, and hearing health insurance services for millions of Americans.

Your allowance is equal to the plan payment for standard lenses, and you'll pay only the difference between the allowance and the discounted price, resulting in substantial savings for you.

As a member of the Avesis Discount Plan 9000, you are entitled to a LASIK Surgery Discount up to 20% off customary charges through a qualified LASIK Avesis provider. Refractive surgery is an elective procedure and may involve potential risks to patients.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232