Dassault Falcon Jet Plan 30556 Vision Claim Form Mail completed claim forms to: Cole Vision Services, Inc. PO Box 8504 Mason, OH 45040-7111 Patient Information (REQUIRED) Last Name … First Name M. I. Identification Number or SSN Street Address City State Postal Code Telephone Birth Date Sex M____ F_____ Relationship to the Subscriber: Self____ Spouse____ Child____ Other ____ Patient Status Employed_____ Full time student_____ Is Patient’s Condition Related to: Employment_____ Auto …

Dassault Falcon Jet Plan 30556 Vision Claim Form Mail completed claim forms to: Cole Vision Services, Inc. PO Box 8504 Mason, OH 45040-7111 Patient Information (REQUIRED) Last Name First Name M. I. Identification Number or SSN Street Address City State Postal Code Telephone Birth Date Sex M____ F_____ Relationship to the Subscriber: Self____ Spouse____ Child____ Other ____ Patient Status Employed______ Full time student_______ Is Patient’s Condition Related to: Employment______ Auto Accident______ Other Accident______ Is there Another Health Benefit Plan Yes____ No____ If yes, complete other insurance information. Subscriber Information (REQUIRED) Last Name First Name M. I. Identification Number or SSN Street Address City State Postal Code Telephone ( ) Birth Date Sex M_____ F_____ Employer’s Name Insurance Plan Name DASSAULT FALCON JET Subscriber’s Group Number 30556
Claim Instructions IMPORTANT: This claim form is intended for subscribers and their dependents that receive services from non- participating providers of Cole Vision Services, Inc. Please note that if a non-participating provider agrees to accept assignment, the provider must submit a CMS-1500 form (also known as a HCFA-1500 form) to Cole Vision Services, Inc. at the address below. If you receive services from a participating provider, no claim form is necessary. Read the following instructions carefully as incorrect, incomplete or illegible claims may result in claim payment being delayed or denied. 1. Enter all requested information in the Patient Information and Subscriber Information sections. Claims may be delayed if information is missing. 2. If you have other insurance, enter all information in the Other Insurance Information section and submit the Explanation of Benefits, if any, received from your other insurance provider. 3. Enter the Name, Address and Telephone number of the provider of services in the Provider Information Section. 4. Attach the original itemized receipts of the services and / or materials you received, including lens type - i.e. Single Vision, Bifocal, or Trifocal - if applicable. 5. Sign and Date the claim form. Mail the completed claim form to: Cole Vision Services, Inc. PO Box 8504 Mason, OH 45040-7111 If you are a subscriber or a dependent of a subscriber and you have any questions, please call 1-800-334-7591. If you are a provider and you have any questions, please call 1-800-655-1558. FRAUD WARNING STATEMENTS Alaska : A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. Arkansas: 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 fines and confinement in prison.

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