AETNA Vision Benefits Request

AETNA Vision Benefits Request

AETNA Vision Benefits Request

AETNA Vision Benefits Request

Kennebec Eye Care​​​​​​​, P.A.

AETNA Vision Benefits Request

To be completed by the employee

Employer's Name

Policy/Group Number

Employee's Aetna ID Number

Employee's Name

Employee's Birthdate

Employee's Address (include Zip Code)

Address is new?

Employee's Daytime Telephone Number

Patient's Name

Patient's Aetna ID Number

Patient's Birthdate

Patient's Relationship to Employee

Patient's Address (if different from employee)

Patient's Gender

Patient's Marital Status

Is the patient employed?

Name and Address of Employer

Is the claim related to an accident?

If yes,

Date

Time

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

Member's Name

Member's Birthdate

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

Date

I authorize payment of vision care benefits to the doctor and/or dispenser.

Patient's or Authorized Person's Signature

Date

To be completed by Doctor or Supplier

Doctor's Name & Address (include Zip Code)

Telephone Number

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

Title

Examination Date(s)

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?

Diagnostic Code(s)

Indicate diagnosis or nature of disease or injury or vision disorder, indicate procedure code number

Visually acuity corrected to

Doctor's Prescription

Sphere

Cylinder

Axis

Prism

Base

Reading Add

Professional Service

Exam (HCPC/CPT)

Sales Tax (if any)

Total

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.

Doctor's Signature

Date

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)

Telephone Number

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

Title

Date

Order

Delivery

Material Supplied

Type of lenses dispensed

Single

Bifocal

Trifocal

Lenticular

Contacts

Sunglasses

Others (specify below)

If contact lenses, please complete

Therapeutic

Non-Therapeutic

Hard Lenses

Soft Lenses

If frame, please complete

Frames

Professional Service

Lens Charge

Frame Charge

Optional

Lens

Frame

Disp. Fee

Lens

Frame

Sales Tax (if any)

Total

Amount Paid by Patient

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.

Dispenser's Signature

Date

chance0524 none 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM 9:00 AM - 5:00 PM 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM Closed Closed optometrist https://www.google.com/maps/place/Kennebec+Eye+Care/@44.5537945,-69.6342705,17z/data=!3m1!4b1!4m5!3m4!1s0x4cb1e47e5bd98651:0x767e5e6208170243!8m2!3d44.5538151!4d-69.6319013 https://www.facebook.com/KennebecEyeCare/reviews/?ref=page_internal