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Georgia Medicaid Vision Forms  
 

If you are interested in participating in this new Medicaid program, you must have, or obtain, a Georgia Medicaid Provider Identification number.

Each form is available in (PDF) format
for you to print or download at your convenience.

 
 

National Provider Identifier (NPI) Application:
Providers across all specialty lines are required to complete a NPI application. If you have not already done so, click this link to be connected to the National Plan & Provider Enumeration System (NPPES) web site.

Get Form

 
 

Vision Authorization Form:
Prior Approval Form to be completed and submitted to Avesis in order to obtain authorization for services such as cataract co-management, medically necessary contact lenses, vision therapy, and replacement glasses

Get Form
 

Non-covered Services:
Enrollees of Georgia Medicaid do have the option of buying up for services or materials. Anytime enrollees has an out-of-pocket responsibility to a provider, the Non-covered Services form must be completed and retained as a permanent part of the patient file.

Get Form

 
 

Option 1 Frame Inventory Form:
Providers selecting Option 1, the delivery of eyeglasses from their own inventory, must complete, submit to Avesis and keep current this inventory form.

Get Form
 

Georgia Correction Industries (GCI) Eyeglass Order Form:
Providers who select Option 2, GCI are required to use this form to place their orders.

Get Form

 

Essilor Provider Application:
Providers utilizing Option 3, Essilor, for the delivery of materials to eligible enrollees of Georgia Medicaid must complete and return to Essilor an account application.

Get Form
 

Essilor/Southern Optical Eyeglass Order Form:
Providers who selected Option 3, Essilor are required to use this form to place their orders.

Get Form

 
 

Electronic Funds Transfer (EFT):
EFT is available to providers on this panel who are utilizing electronic mediums for eligibility verification and claims submission.

Get Form
 

Credentialing Checklist:
Details all required credentialing materials to be submitted to Avesis.

Get Form

 

       
 
Send Completed Materials by mail or fax to Provider Services
Mail To:
Avesis Third Party Administrators
Attn: Provider Services
P.O. Box 782
Owings Mills, MD 21117

Phone:
800-231-0979

Send e-mail
Providers in need of a State of Georgia provider identification number can receive that here »

 
       
 

 
     
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