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Many NVA vision plans allow members the choice to visit an Participating Vision Care Provider or Non-
participating Vision Care Provider. If you do decide to use a Non-participating Provider and your vision
benefit allows out of network coverage you can submit a direct claim to NVA for reimbursement
according to your benefits. Please reference your NVA vision benefit to ensure you have out of network
coverage.
VISION CLAIM FORM INSTRUCTIONS
Use this form to obtain reimbursements for out of network services according to
your plan design
Part A to be completed by Employee
Part B to be completed by your Eye Care Professional (Optional)
Part C to be completed by your Eyewear Dispenser
Scan and submit form by e-mail to: visionclaims@e-nva.com
Submit the form by fax to: (973) 574-2430
Submit the form by mail to: National Vision Administrators, L.L.C.
P.O. Box 2187
Clifton, New Jersey, 07015
Include a copy of your receipts with your completed vision care claim form
If you have any questions, please contact NVA at (800) 672-7723
National Vision Administrators, L.L.C.
OUT OF NETWORK
VISION CARE CLAIM FORM
PLEASE PRINT INFORMATION
PART A: TO BE COMPLETED BY EMPLOYEE
1. EMPLOYEE’S NAME (LAST, FIRST, MIDDLE)
2. EMPLOYEE’S ADDRESS (No., Street, City, State, Zip Code)
3. EMPLOYER’S IDENTIFICATION #
4. EMPLOYEE’S TELEPHONE #
5. EMPLOYER’S NAME
6. EMPLOYER’S ADDRESS (No., Street, City, State, Zip Code)
7. PATIENT’S NAME (LAST, FIRST, MIDDLE)
8. PATIENT’S RELATIONSHIP TO EMPLOYEE
10. PATIENT’S
DATE OF BIRTH
□ SELF
□ CHILD
□ STUDENT
□ SPOUSE
□ HANDICAPPED
□ OTHER _______
11. IS PATIENT COVERED BY
ANOTHER VISION PLAN?
□
YES
□
NO
VISION PLAN NAME
GROUP #
NAME AND ADDRESS OF CARRIER
12. Anyone who knowingly and with intent to defraud any insurance company or other person; files an application for insurance or statement of claim
containing any materially false information; or conceals for the purpose of misleading information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subject such person to criminal and civil penalties.
PART B: TO BE COMPLETED BY EYE CARE PROFESSIONAL (OPTIONAL)
1. DOCTOR’S NAME (LAST, FIRST, MIDDLE)
2. TAX PAYER IDENTIFICATION #
3. BUSINESS PHONE # (area code)
4. TITLE:
□ MD
□ DO
□ OD
5. DOCTOR’S ADDRESS (No., Street, City, State, Zip Code)
6. PROFESSIONAL SERVICE
7. AMOUNT
8. EXAMINATION DATE
9. WAS CATARACT SURGERY
PERFORMED?
□ YES
□NO
EYE EXAMINATION
$
10. CAN VISUAL ACUITY BE RESTORED TO 20/70 IN BETTER EYE WITH
CONVENTION EYEGLASSES?
□ YES
□NO
CONTACT LENS EXAM (if any)
$
11. DOES PATIENT REQUIRE A PRESCRIPTION CHANGE AT THIS TIME?
□ YES
□NO
AMOUNT PAID BY PATIENT
$
12. DIAGNOSTIC CODE(s)
13. INDICATE DIAGNOSIS OR NATURE OF DISEASE, INJURY, VISION DISORDER. CODE #’S INDICATE PROCEDURE
14. VISUAL ACUITY CORRECTED TO:
15. Doctor’s Prescription
16. I hereby certify that I have performed the services as indicated
heron.
SPHERE
CYLINDER
AXIS
PRISM
BASE
R.E.
●
L.E.
●
READING ADD
R.E.
+ ●
L.E.
+ ●
DOCTOR’S SIGNATURE
DATE
PART C: TO BE COMPLETED BY DISPENSER
1. DISPENSER’S NAME (LAST, FIRST, MIDDLE)
2. TAX PAYER IDENTIFICATION #
3. DISPENSER’S ADDRESS (No., Street, City, State, Zip Code)
4. BUSINESS PHONE # (area code)
5. PROFESSIONAL SERVICES
DATE(S) OF SERVICE
PLACE
OF
SERVICE
TYPE OF
SERVICE
PROCEDURES, SERVICES, OR
SUPPLIES (Explain unusual
circumstances)
DIAGNOSIS
CODE
$ CHARGES
DAYS OR
UNITS
FROM
TO
CPT/HCPC
MODIFIER
MM
DD
YY
MM
DD
YY
6. PATIENT’S ACCOUNT #
7. TOTAL CHARGED
$
8. AMOUNT PAID
$
9. BALANCE DUE
$
10. I hereby certify that I have performed the services as indicated hereon.
DISPENSER’S SIGNATURE
DATE
Scan and submit via e-mail: visionclaims@e-nva.com or submit via fax at 973-574-2430
National Vision Administrators, L.L.C.
VISION CARE CLAIM FORM
NATIONAL VISION ADMINISTRATORS, L.L.C.
P.O. BOX 2187 / CLIFTON, NJ 07015
800-672-7723
Page 1 of 2
FRAUD NOTICE: For the states of AL, AZ, AR, CA, CO, DE, DC, FL, GA, IN, KS, KY, LA, MD, ME,
NC, NE, NJ, NM, OK, OR, PA, RI, TN, TX, VA, VT, WA and WV, please refer to the following fraud
notices:
Alabama: Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit
or who knowingly presents false information in an application for insurance is guilty of a crime and may
be subject to restitution, fines or confinement in prison, or any combination thereof.
Arizona:
For your protection, Arizona law requires the following statement to appear on this
form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is
subject to criminal and civil penalties.
Arkansas, Louisiana, Rhode Island, West Virginia: Any person who knowingly presents a false or
fraudulent claim for payment of loss or benefit or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to fines and confinement in prison.
California: For your protection, California law requires the following to appear on this form: Any person
who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may
be subject to fines and confinement in state prison.
Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of
an insurance company who knowingly provides false, incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or
claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the
Colorado Division of Insurance within the Department of Regulatory Agencies.
Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a
statement of claim containing any false, incomplete or misleading information is guilty of a felony.
District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer
for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or
fines. In addition, an insurer may deny insurance benefits if false information materially related to a
claim was provided by the applicant.
Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete, or misleading information is guilty
of a felony of the third degree.
Georgia, Oregon, Vermont: Any person who with intent to defraud or knowing that he/she is
facilitating a fraud against an insurer, submits an application or files a claim containing a false or
deceptive statement may be guilty of insurance fraud.
Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim
containing any false, incomplete, or misleading information commits a felony.
National Vision Administrators, L.L.C.
Page 2 of 2
Kansas: Any person who with intent to defraud or knowing that he or she is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement may be
guilty of insurance fraud as determined by a court of law.
Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person
files a statement of claim containing any materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is
a crime.
Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly and willfully presents false information in an application for insurance is
guilty of a crime and may be subject to fines and confinement in prison.
Maine, Tennessee, Washington: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company. Penalties may
include imprisonment, fines or a denial of insurance benefits.
Nebraska: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud
against an insurer, submits an application or files a claim containing false, incomplete or misleading
information is guilty of insurance fraud.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime and
may be subject to civil fines and criminal penalties.
North Carolina: Any person with the intent to injure, defraud, or deceive an insurer or insurance
claimant is guilty of a crime (Class H felony) which may subject the person to criminal and civil
penalties.
Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or
misleading information is guilty of a felony.
Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false
information or conceals, for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties.
Texas: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of
a crime and may be subject to fines and confinement in state prison.
Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement may have
violated state law.
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Completed 31 January 2021

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