Get Avesis Vision Benefits Claim Form - Bugpinccomb

This guide provides clear instructions to help you accurately complete the Avesis Vision Benefits Claim Form - Bugpinccomb online. Following these steps will assist you in filing your claim smoothly and efficiently.

Follow the steps to fill out the form correctly

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin with the fields for the patient's information by entering the patient's name, including last, first, and middle names in the designated field.
3. Next, fill in the patient's birth date accurately in the specified section.
4. Indicate the patient's sex by selecting either 'male' or 'female' in the provided options.
5. Enter the cardholder's address details, including the street address, city, state, and zip code.
6. Fill in the cardholder’s ID number in the respective field.
7. Provide the cardholder's name using the same format as the patient’s name.
8. Record the cardholder’s home and work phone numbers in the designated areas.
9. Specify the name of the insurance carrier in the field provided.
10. Enter the cardholder’s group number and select their relationship to the cardholder from the options provided.
11. If the patient is covered for vision care by another plan, indicate 'yes' or 'no' and, if affirmative, complete the additional fields for other insurance details.
12. Sign and date the form in the appropriate sections, affirming the accuracy of the provided information.
13. Detail the services rendered by the eye care provider including date of service, provider's name, and the services provided.
14. Confirm that you have listed an itemized receipt or superbill to accompany the claim.
15. Once you have filled in all required fields, review the form for accuracy, and save the changes. You can then download, print, or share the completed form as needed.

Complete your documents online to ensure a smooth claim submission process.