Fill Out Online
Adobe Acrobat.




Provider Utilization Report

Patient Name
Primary Member's Name (if different)
VPA Group/Member #
Date of Service

Services Provided: (Check applicable)

Eye Exam Lenses
S/V
B/F
T/F
Other 		Frames Contact Lenses Aphakic
OD
OS

If other, please explain:

Does patient have any Eye Medical condition that does not require referral: Yes       No

If yes, what is the diagnosis:

Provider Name: Facility Number:
Address:
Telephone:
Fax:
Medical Referral (if applicable) to:

Dr.
Telephone:

Date:

**Provider, we welcome your comments:



CIA is an affiliate of
Vision Plan of America.

QualSight Preferred
LASIK Pricing