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Check your elibility from the list below:

Frames

Benefit available

Benefit unvailable

Lenses

Benefit available

Benefit unvailable

Contact lenses

Benefit available

Benefit unvailable

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AUTHORIZATION FOR REQUEST OF CONFIDENTIAL COMMUNICATION OF MEDICAL INFORMATION

I request access as the Patient Parent/Guardian Authorized Assistant (Proof of legal documentation required)

Name of Patient Date of Birth

Address City State Zip Code

Contact number

Today's Date:

Communication this request will cover for confidentiality

Bill
Notice of adverse benefit determination
Explanation of Benefits
Information regarding claims
Notice of contested claims

Preferred method of communication:

Written:

Address to send correspondence:

Electronic: Email to send correspondence:

Verbal/live: Telephone contact to send correspondence:

Duration: This authorization is valid until the subscriber or enrollee submits a revocation of the request or a new confidential communication request is submitted, without an annual renewal requirement.

Date:

Patient Name (Print): Daytime contact #:

Signature of patient or patient's representative relationship to patient

AUTHORIZATION FOR REQUEST OF CONFIDENTIAL COMMUNICATION OF MEDICAL INFORMATION

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AUTHORIZATION FOR REQUEST OF CONFIDENTIAL COMMUNICATION OF MEDICAL INFORMATION