ATTENTION MEMBER Please present this claim form at the

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ATTENTION MEMBER Please present this claim form at the Powered By Docstoc
					ATTENTION MEMBER: Please present this claim form at the time services are rendered.
Please forward claims to:
Medical Eye Services
PO Box 25209 • Santa Ana, CA 92799
(800) 877-6372 • (714) 619-4660
www.mesvision.com

CLAIM SUBMITTED FOR:                                EXAM ONLY ❏                     MATERIALS ONLY ❏                             EXAM & MATERIALS ❏
                                                       PART 1. TO BE COMPLETED AND SIGNED BY THE INSURED
PATIENT’S NAME (LAST, FIRST)                                                              SEX                                       EMPLOYEE’S IDENTIFICATION NUMBER
                                                                                             MALE ❏      FEMALE ❏
EMPLOYEE’S NAME                                                                           RELATIONSHIP TO EMPLOYEE                  PATIENT’S BIRTHDATE (Month/Day/Year)
                                                                                             SELF ❏   SPOUSE ❏   CHILD ❏
STREET ADDRESS                                                                            NAME OF EMPLOYER                          GROUP POLICY NUMBER

CITY, STATE, ZIP

OTHER VISION COVERAGE? IF “YES,” GIVE NAME OF CARRIER AND POLICY NUMBER WAS CARE REQUIRED BECAUSE OF AN INJURY OR ILLNESS? IF “YES,” PLEASE EXPLAIN
   YES ❏    NO ❏                                                          YES ❏     NO ❏
IF DEPENDENT IS OVER CONTRACT AGE LIMIT, IS HE/SHE A FULL-TIME STUDENT? STUDENT’S SOCIAL SECURITY NUMBER    NAME OF SCHOOL
   YES ❏       NO ❏

              The above answers are true and complete according to the best of my knowledge and belief. I hearby authorize my
           doctor to furnish and disclose all facts concerning this claim. I hereby assign payable benefits to participating providers.


            SIGNATURE                                                                          DATE

                    PART 2. TO BE COMPLETED BY DOCTOR                                                        PART 3. TO BE COMPLETED BY DISPENSER
DATE OF EXAMINATION                                  REFRACTION                               DATE OF ORDER             DATE OF DEL.             SINGLE VISION ❏ BIFOCAL ❏
                                                                                                                                                 TRIFOCAL ❏ PROGRESSIVE ❏
                                                     NO REFRACTION                                                                                       CONTACT ❏

IF YOU PRESCRIBED GLASSES, CHECK ALL THAT APPLY                                               RIGHT LENS CHARGE                                  $

   SINGLE VISION ❏ BIFOCAL ❏             TRIFOCAL ❏     PROGRESSIVE ❏        CONTACT ❏        LEFT LENS CHARGE                                   $

HAS CATARACT SURGERY BEEN PERFORMED?                                                          OVERSIZE CHARGE, IF ANY                            $

 YES ❏       NO ❏                                   DATE _____________________________         ❏ PRISM CHARGE      ❏ OTHER____________           $
                                                                                               ❏ SLAB OFF CHARGE___________________
IS THIS A PRESCRIPTION CHANGE FROM                  BEST CORRECTED VISUAL ACUITY
LAST YEAR?    YES ❏     NO ❏                        R.E. 20/           L.E. 20/               TINT CHARGE                                        $
RVS/CPT            EXAMINATION FEE              RVS/CPT          OTHER CHARGES                COLOR______________ NO. _____________
                   $                                             $
                                                                                              FRAME CHARGE                                       $
                                 DOCTOR’S PRESCRIPTION                                        NAME OF FRAME _______________________
                    Sphere           Cylinder          Axis          Prism         Base
                                                                                              IS FRAME LESS THAN:                                    61 MM ❏   56 MM ❏

R.E.                                     .
                                                                                              CONTACT LENS CHARGE                                $
                                                                                               ❏ HARD     ❏ SOFT
L.E.                  .                  .
                                                                                              TOTAL FOR OPTICAL MATERIALS                        $
READING ADD               R.E.                            L.E.
                                     +          .                    +        .
SPECIAL INSTRUCTIONS                                                                          COMMENTS



SIGNATURE                                                     DATE                            SIGNATURE                                                DATE


PLEASE PRINT OR TYPE NAME OF DOCTOR                           PARTICIPATING PROVIDER NO.      PLEASE PRINT OR TYPE NAME OF DISPENSARY                PARTICIPATING PROVIDER NO.

STREET ADDRESS                                                                                STREET ADDRESS


CITY, STATE, ZIP                                                                              CITY, STATE, ZIP


EXAMINATION ELIGIBILITY VERIFICATION NO.                                                      MATERIALS ELIGIBILITY VERIFICATION NO.


                                  For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or
                                       fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

   PDV-703-48509
   PDVCA39E490
   07/03