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.

For your convenience, each form is available in (PDF) formatpdf for you to print or download.

National Provider Identifier (NPI) Application:

Providers across all specialty lines are required to have a NPI number. If you have not already done so, click this link to be connected to the National Plan & Provider Enumeration System (NPPES) web site to apply for your NPI number. Get Form

Avesis Eye Medical Provider Application

Ophthalmologists new to Avesis or who have not completed an application within the past thirty (30) months should complete a new application. Get Form

Avesis Eye Medical Provider Agreement

The Provider Agreement outlines the contractual arrangement between "the provider" and Avesis. Get Form

Avesis Eye Medical Group Agreement

The Group Agreement outlines the contractual arrangement between a multi -provider group practice and Avesis. Get Form

Avesis Routine Eye Care Provider Application

Providers new to Avesis or who have not completed an application within the past thirty (30) months should complete a new application. Get Form

Eye Care Vision Provider Agreement

The Provider Agreement outlines the contractual arrangement between "the provider" and Avesis. Get Form

Addendum to Provider Agreement

The Addendum to the Eye Medical and Eye Care Provider Agreement has been updated and approved by DCH. Get Form

Non-covered Services

Enrollees of Georgia Medicaid do have the option of buying up for services or materials. Anytime an enrollee 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

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/Select 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

Provider Election Form

Select from three vision benefits program options for the Georgia Medicaid program.
Get Form

Avesis Georgia Medicaid Eye Medical Authorization Form

This document is a determination of a request for authorization to perform services that require prior approval.
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

Email:
Send e-mail

Providers in need of a State of Georgia provider identification number can receive that here »