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