Vision Insurance Benefits Request

1
Your current vision insurance provider* This field is required.Please select all that apply.
VSP
Superior
Spectera
EyeMed
Davis Vision
Cigna Vision
Blue View
Aetna Vision
Other
2
By selecting "AGREE" below, you are agreeing to release the provided information in order for Family Tree Optometric to access your insurance benefits information. When services are rendered, you are also agreeing to allow Family Tree Optometric to submit your information to your insurance provider, in order to file a claim on your behalf.* This field is required.
AGREENO
3
Full Name* This field is required.Name of primary member insured
First Name
Middle Name
Last Name
Suffix
4
Sex* This field is required.This is required by the vision insurance providers.
MaleFemale
5
Birthdate* This field is required.of primary insured
MM/DD/YYYY
6
Last 4 digits of Social Security Number of Primary Plan Member* This field is required.Insurance company requires this information
Only the last 4 digits
7
Member ID numberInsurance company requires this information
8
Address* This field is required.of primary insured
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Is this plan provided by an employer?* This field is required.
YESNO
10
Employer or Group Name* This field is required.
11
Individual Plan Number* This field is required.
12
(1) Would you like to add a dependent? * This field is required.
YESNO
13
1. Additional person on insurance to check
First Name
Middle Name
Last Name
Suffix
14
(1) Birthdateof additional insured person
MM/DD/YYYY
15
(2) Would you like to add another dependent?
YESNO
16
2. Additional person on insurance to check
First Name
Middle Name
Last Name
Suffix
17
(2) Birthdateof additional insured person
MM/DD/YYYY
18
(3) Would you like to add another dependent?
YESNO
19
3. Additional person on insurance to check
First Name
Middle Name
Last Name
Suffix
20
(3) Birthdateof additional insured person
MM/DD/YYYY
21
(4) Would you like to add another dependent?
YESNO
22
4. Additional person on insurance to check
First Name
Middle Name
Last Name
Suffix
23
(4) Birthdateof additional insured person
MM/DD/YYYY
24
(5) Would you like to add another dependent?
YESNO
25
5. Additional person on insurance to check
First Name
Middle Name
Last Name
Suffix
26
(5) Birthdateof additional insured person
MM/DD/YYYY
27
(6) Would you like to add another dependent?
YESNO
28
6. Additional person on insurance to check
First Name
Middle Name
Last Name
Suffix
29
(6) Birthdateof additional insured person
MM/DD/YYYY
30
(7) Would you like to add another dependent?
YESNO
31
7. Additional person on insurance to check
First Name
Middle Name
Last Name
Suffix
32
(7) Birthdateof additional insured person
MM/DD/YYYY
33
(8) Would you like to add another dependent?
YESNO
34
8. Additional person on insurance to check
First Name
Middle Name
Last Name
Suffix
35
(8) Birthdateof additional insured person
MM/DD/YYYY
36
(9) Would you like to add another dependent?
YESNO
37
9. Additional person on insurance to check
First Name
Middle Name
Last Name
Suffix
38
(9) Birthdateof additional insured person
MM/DD/YYYY
39
(10) Would you like to add another dependent?
YESNO
40
10. Additional person on insurance to check
First Name
Middle Name
Last Name
Suffix
41
(10) Birthdateof additional insured person
MM/DD/YYYY
42
Phone Number* This field is required.We will contact you after checking your benefits.
Area Code
Phone Number
43
EmailIn order to send you additional information upon request only. We do not share your email address with anyone and we do not sell your information to a 3rd party.
example@example.com
44
Please verify that you are human* This field is required.
45
We are open access to all patients regardless of an insurance company, coverage, or benefits. Unfortunately, not all vision insurance companies provide us with available benefits information.

The good news is, you can still schedule an appointment and be seen by a Family Tree Optometric doctor!

Please give us a call for further assistance. 949-733-1400
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