Vision Claim Form
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1Blue Shield of California and Blue Shield of California
Life & Health Insurance Company – Vision claim form
Please forward claims to: Blue Shield of California, P.O. Box 25208, Santa Ana, CA 92799-5208. (877) 601-9083 members or (800) 877-6372 providers. The participating
provider must call MESVision to obtain an Eligibility Verification Number. 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 a
state prison. Note: Please complete the entire form. This form cannot be processed if information is incomplete. Important: Please print all sections in black ink.
PATIENT'S NAME (Last Name, First)
G
E
N
D
E
R
E
M
P
L
O
Y
E
E
S '
D I
E
N
T
F I
C I
A
I T
O
N
N
O
.
MALE
FEMALE
EMPLOYEE'S NAME
RELATIONSHIP TO EMPLOYEE
PATIENT'S BIRTHDATE
MONTH
DAY
YEAR
SELF
SPOUSE
CHILD
/
/
ADDRESS
DOMESTIC PARTNER
DOMICILE ADULT
DISABLED
N
A
M
E
O
F
E
M
P
L
O
Y
E
R
G
R
O
U
P
P
O
L
C I
Y
N
U
M
B
E
R
CITY, STATE, and ZIP CODE
WAS CARE REQUIRED BECAUSE OF AN INJURY OR ILLNESS?
IF "YES," PLEASE EXPLAIN:
EMAIL
NO
YES
IS PATIENT FULL-TIME STUDENT?
NO
YES
SCHOOL NAME:
OTHER VISION COVERAGE? IF "YES," GIVE NAME OF CARRIER AND POLICY NUMBER
POLICY NUMBER:
NAME OF CARRIER:
YES
NO
The above answers are true and complete according to the best of my knowledge and belief. I hereby authorize my doctor to furnish and
disclose all facts concerning this claim. I hereby assign payable benefits to participating providers.
SIGNATURE
DATE
VERIFICATION #:
VERIFICATION #:
CHECK CONDITIONS PATIENT IS KNOWN TO HAVE
MONTH
DAY
YEAR
MONTH
DAY
YEAR
DATE OF ORDER:
DELIVERY DATE:
/
/
/
/
DIABETES
HIGH CHOLESTEROL
HYPERTENSION
GLAUCOMA
OTHER CONDITIONS/ DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (ICD 9 / 10 Codes)
EYEWEAR
CHARGE
HCPC/CPT CODES
D
a i
g
n
o
s
s i
:
D
a i
g
n
o
s
s i
:
L
R
$
Diagnosis :
Diagnosis :
L
R
$
DILATION :
YES
NO
RETINAL PHOTOS :
YES
NO
PRESCRIBED
L
R
$
Single Vision
Bifocal
Trifocal
Progressive
Contacts
Rx
S
p
h
e
e r
A
x
s i
C
y
n i l
d
r e
r P
s i
m
B
a
s
e
C
u
v r
e
L
R
$
R.E.
L
R
$
L.E.
L
R
$
READING ADD
R.E.
L.E.
+
+
L
R
$
MONTH
DAY
YEAR
MONTH
DAY
YEAR
EXAM
CL FITTING
/
/
/
/
DATE:
DATE:
L
R
$
HCPC/CPT CODES
CHARGES
BRAND
$
CONTACTS
$
FRAME NUMBER
FRAME
$
$
IS FRAME SIZE LESS THAN
56
61
PLANO SUNGLASSES
PROOF OF LASIK SURGERY MAY BE
$
$
REQUIRED FOR SUNGLASS BENEFIT
(PREFABRICATED / NON-RX)
COB:
List the total overage on this line
$
$
COB itemized charges above must be patient out of pocket
TOTAL EXAM CHARGES
$
TOTAL FOR OPTICAL MATERIALS
$
0.00
0.00
NAME OF DOCTOR
PARTICIPATING PROVIDER NO.
NAME OF DISPENSARY
PARTICIPATING PROVIDER NO.
EMAIL ADDRESS
EMAIL ADDRESS
NPI NO.
NPI NO.
ADDRESS
ADDRESS
CITY, STATE and ZIP CODE
CITY, STATE and ZIP CODE
I S
G
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D
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I S
G
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D
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Rev 2012
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