Dental and Vision Forms
| Title | Purpose | Number |
|---|---|---|
| Authorization to Release Health-Related Information | Authorize The Standard to release dental and/or vision insurance information to a designated recipient. | 11702 |
| Balanced Care Vision Plan III Claim | Use this form to initiate an eye care claim. | SI 14068 |
| Dental Claim | Use this form to report a treatment plan and to initiate a dental claim. | SI 3943 |
| Dental Claim (NY Only) | Use this form to report a treatment plan and to initiate a dental claim. For use in New York only. | SNY 3943 |
| Eye Med Vision Out of Network Claim | Used to initiate an out of network eye care claim. | SI 14070 |
| Vision Claim Form | Use this form to initiate a vision claim. | SI 14068 |
| Vision Claim Form (NY Only) | Use this form to initiate a vision claim. For use in New York only. | SNY 14069 |
| Vision Claim Form (Spanish - NY Only) | Use this form to initiate a vision claim (Spanish). For use in New York only. | SNY 14069 SPU |
| Vision Claim Form (Spanish) | Use this form to initiate a vision claim (Spanish). | SI 14068 SPU |
| VSP Vision Out of Network Claim | Used to request out of network eye care expense reimbursement. | SI 14071 |