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Click ‘Get Form’ to open the NYSNA Optical Form in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's name, birth date, and relationship to the member. If applicable, indicate if they are a full-time college student.
Next, complete the 'Member/Employee' section with your details including name, birth date, address, social security number, and contact information.
In the 'Spouse Information' section, provide your spouse's name and birth date. Indicate if they are covered by another benefits plan and include their employer's details.
Fill out the 'Provider Information' sections for both the examiner and dispenser of frames and lenses. Include names, addresses, license numbers, and contact information.
Complete any necessary certifications regarding accidents or injuries related to this claim.
Finally, sign the authorization to release information and assignment of benefits sections before submitting your form.

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Versions	Form popularity	Fillable & printable
2009	4.8 Satisfied (65 Votes)

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