Avesis Out-of-Network Claim Form

Members are only responsible for filing a claim if they receive vision care services from a provider that is not currently participating in the Avesis network. At point of service, the member would be responsible for making payment-in-full of all charges to the non-Avesis provider. Afterwards, to receive reimbursement up to the plan specified schedule of allowances, members must fill out the attached form and mail it along with their receipts to:

Avesis Third Party Administrators, Inc.
Vision Claims Department
P.O. Box 38300
Phoenix AZ 85069-8300

Download Form