To be completed by the employee
Employee's Aetna ID Number
Employee's Address (include Zip Code)
Address is new?
Employee's Daytime Telephone Number
Patient's Aetna ID Number
Patient's Relationship to Employee
Patient's Address (if different from employee)
Patient's Marital Status
Is the patient employed?
Name and Address of Employer
Is the claim related to an accident?
Is the claim related to employment?
Are any family members' expenses covered by another group health plan, group pre-payment plan (Blue Cross-Blue Shield, etc.), no-fault auto insurance, Medicare, or any federal, state, or local government plan?
If yes, list policy or contract holder, policy or contract number(s) and name/address of insurance company or administrator
Member's ID Number
To all providers of health care:You are authorized to provide Aetna Life Insurance Company or one of its affiliated companies ("Aetna"), and any independent claim administrators and consulting health professionals and utilization review organizations with whom Aetna has contracted, information concerning health care advice, treatment, or supplies provided the patient (including that relating to mental illness and/or AIDS/ARC/HIV). This information will be used to evaluate claims for benefits. Aetna may provide the employer named above with any benefit calculation used in payment of this claim for the purpose of reviewing the experience and operation of the policy or contract. This authorization is valid for the term of the policy or contract under which a claim has been submitted. I know that I have a right to receive a copy of this authorization upon request and agree that a photographic copy of this authorization is as valid as the original.
Patient's or Authorized Person's Signature
I authorize payment of vision care benefits to the doctor and/or dispenser.
To be completed by Doctor or Supplier
Doctor's Name & Address (include Zip Code)
Enter the taxpayer identifying number to be used for 1099 reporting purposes. You are required under the authority of law to furnish your taxpayer identifying number.
National Provider Identifier
Has Cataract surgery been performed?
Can visual acuity be restored to 20/70 in better eye with conventional eyeglasses?
Does the patient require a prescription change at this time?
Indicate diagnosis or nature of disease or injury or vision disorder, indicate procedure code number
Visually acuity corrected to
Sales Tax (if any)
Amount Paid by Patient
I hereby certify that the procedures as indicated by date have been completed and that the fees submitted are the actual fees I have charged this patient and intend to accept for those procedures.
Note: In lieu of dispenser completing this section a laboratory bill can be attached. Dispenser must sign this form, enter the amount paid by the patient.
Dispenser's Name & Address (include Zip Code)
Type of lenses dispensed
Others (specify below)
If contact lenses, please complete
If frame, please complete
Sales Tax (if any)
I hereby certify that I have performed the services as indicated hereon and that the fees submitted are the actual fees I have charged this patient and intend to accept for those procedures.
All EyeCare Services
At Kennebec Eye Care, we provide the highest quality optometry services to all of our patients. Schedule your appointment today.
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