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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.

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ACH for Dental & Vision Customers Based Outside NY

Use this form to request and authorize an agreement for prearranged payments via Automated Clearing House.

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Authorization to Release Health-Related Information

Authorize The Standard to release dental and/or vision insurance information to a designated recipient.

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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.

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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)

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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.

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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.

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EFT for Dental & Vision Customers Based Outside NY

Use this Electronic Funds Transfer form to request and authorize a bank payment plan.

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Eye Med Vision Out of Network Claim

Used to initiate an out of network eye care claim.

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Vision Claim Form (All states except NY)

Use this form to initiate a vision claim.

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Vision Claim Form (NY)

Use this form to initiate a vision claim. For use in New York only.

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Vision Claim Form (Spanish - All states except NY)

Use this form to initiate a vision claim (Spanish).

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Vision Claim Form (Spanish - NY)

Use this form to initiate a vision claim (Spanish). For use in New York only.

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VSP Vision Out of Network Claim

Used to request out of network eye care expense reimbursement.

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