Forms
| Title | Purpose | Action |
|---|---|---|
| ACH for Dental & Vision Customers Based in NY | Use this form to request and authorize an agreement for prearranged payments via Automated Clearing House. For use in New York only. |
Download |
| ACH for Dental & Vision Customers Based Outside NY | Use this form to request and authorize an agreement for prearranged payments via Automated Clearing House. |
Download |
| Authorization to Release Health-Related Information | Authorize The Standard to release dental and/or vision insurance information to a designated recipient. |
Download |
| Authorization to Release Health-Related Information (NY) | Authorize The Standard to release dental and/or vision insurance information to a designated recipient. For use in New York only. |
Download |
| Authorization to Release Health-Related Information (Spanish - All states except NY) | Authorize The Standard to release dental and/or vision insurance information to a designated recipient. (Spanish) |
Download |
| Authorization to Release Health-Related Information (Spanish - NY) | Authorize The Standard to release dental and/or vision insurance information to a designated recipient. (Spanish) For use in New York only. |
Download |
| EFT for Dental & Vision Customers Based in NY | Use this Electronic Funds Transfer form to request and authorize a bank payment plan. For use in New York only. |
Download |
| EFT for Dental & Vision Customers Based Outside NY | Use this Electronic Funds Transfer form to request and authorize a bank payment plan. |
Download |
| Eye Med Vision Out of Network Claim | Used to initiate an out of network eye care claim. |
Download |
| Vision Claim Form (All states except NY) | Use this form to initiate a vision claim. |
Download |
| Vision Claim Form (NY) | Use this form to initiate a vision claim. For use in New York only. |
Download |
| Vision Claim Form (Spanish - All states except NY) | Use this form to initiate a vision claim (Spanish). |
Download |
| Vision Claim Form (Spanish - NY) | Use this form to initiate a vision claim (Spanish). For use in New York only. |
Download |
| VSP Vision Out of Network Claim | Used to request out of network eye care expense reimbursement. |
Download |