Mail Completed Claim Forms to: CLAIM FORM HealthSCOPE ...
VISION CARE CLAIM FORM
PART I -- PATIENT & MEMBER INFORMATION (To be completed by member) (Please print or type)
Mail Completed Claim Forms to: HealthSCOPE Benefits, Inc. P. O. Box 99003 Lubbock, TX 79490-9003
1. PATIENT'S NAME (first name, middle initial, last name)
5. MEMBER'S NAME (first name, middle initial, last name) 8. MEMBER'S STREET ADDRESS
Check here if new address
2. Patient's Relationship to member
Self
Spouse Child
Other
3. Patient's Date of Birth Age
6. Is patient a full-time student 19 years of age or over?
No
Yes
7. Name of School
9. Member's Identification No. (Shown on your ID card)
4. Patient's Sex:
Male
Female
Patient Marital Status: Single Married
10. CITY
STATE
ZIP
11. EMPLOYER./GROUP NAME
13. GROUP NO.
14. Is treatment due to an accident? No Yes If YES, give date of accident Give brief description, when, where & how?
12. Do you or your spouse have other medical/vision coverage?
No
Yes
If YES, please attach the "Explanation of Benefits" form showing the action taken by the other insurance company and complete the following:
Member's Name: Member's Date of Birth: Name of Other Benefits Administrator: Location of Other Benefits Administrator:
Member's Employer: Contract/Social Security No:
15. Member of Authorized Person's Signature
See instructions "NOTE" on back.
A. I authorize release to HealthSCOPE Benefits, any and all information pertaining to this claim. I certify that the information provided is true and complete.
B. I certify that I paid the provider's charge in full and would like HealthSCOPE Benefits to issue payment to me.
Check one box only
I authorize HealthSCOPE Benefits to issue payment to the provider indicated on this claim.
Member of Authorized Person's Signature
(Date)
Member or Authorized Person's Signature
(Date)
PART II--TO BE COMPLETED BY PROVIDER OF SERVICES
Date of Service
Description of Services Or Supplies
Single OD
Vision OS
Bifocal OD
Bifocal OS
Please Check Type of Lens Dispensed
Trifocal OD
Trifocal OS
Lenticular OD
Lenticular OS
Contacts Contacts
OD
OS
CHARGES
DIAGNOSIS:
FRAME EXAM
Provider's Name, Address, Zip & Telephone No.
REFRACTION RX:
Additional Comments:
Total Charge
I certify that these services have been performed and that supplied have been dispensed.
Signature of Provider
Federal Tax ID No.
Date
Suffix
For Carrier Use Only:
CLAIM FILING INSTRUCTIONS
Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against a benefits administrator, submits an application or files a claim containing false or deceptive statement, if guilty of health care fraud.
Help us reduce health care costs by reporting health care fraud. CALL 1-800-333-4585.
TO THE MEMBER: Complete all items in Blocks 1 thru 15 so that eligibility of the patient can be properly determined. (The Member's Authorized Person's signature and the date signed is required in Block 15A. After you complete Part I, give the form to your doctor or provider to fill out. Please have a copy of the itemized bill submitted with the claim form.
NOTE: If the Provider of Services is a HealthSCOPE Benefits provider, payment will automatically be issued to the provider unless you have clearly indicated in Block 15B that the bill has been paid in full.
If you have any questions about filing claims, call Customer Service at:
1-800-229-2156 (Toll-Free)
TO THE PROVIDER: Complete all items in Part II. (The Internal Revenue Service requires we identify, record and report payments received from Central Benefits Administrators. To comply with this requirement, please furnish your Federal Tax Identification Number.)
Mail completed claim forms to:
HealthSCOPE Benefits, Inc. P. O. Box 99003 Lubbock, TX 79490-9003
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