Routine Vision Benefit Reimbursement Form Oxford Health Plans, Attn: Claims, P.O. Box 7086, Bridgeport, CT

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1 Routine Vision Benefit Reimbursement Form Oxford Health Plans, Attn: Claims, P.O. Box 7086, Bridgeport, CT Davis Vision % (Member Name) (Member Signature) (Member's Oxford ID #) (Member's Address) (Provider Name) (Provider's Address) (Please indicate below the services for which you are seeking reimbursement) (Eye Exam) a. (The cost of the exam:) / (Glasses/Contact Lenses) a. (The cost of the frames:) b. (The cost of the lenses:) c. / (Is this request for reimbursement of post-cataract glasses/contact lenses following cataract surgery?) (YES) (NO) (If yes, date of cataract surgery): MS NEW YORK OMA MOSAIC NYC D-199

2 Davis Vision 戴 維 斯 視 覺 服 務 中 心 MANHATTAN 曼 哈 頓 Canal Street Optical Inc. 永 裕 眼 鏡 公 司 158 Canal Street 堅 尼 路 街 158 號 New York, NY 電 話 :(212) (212) Chinatown Optical Inc. 華 埠 眼 鏡 公 司 40 Mott Street 勿 街 40 號 New York, NY 電 話 : (212) (212) Kai Wing Wai 韋 啓 榮 Elizabeth Street Suite 401 伊 利 沙 白 街 號 401 室 New York, NY 電 話 : (212) (212) Mott Street Optical Inc. 永 昌 眼 鏡 公 司 52 Mott Street 勿 街 52 號 New York, NY 電 話 : (212) (212) Pacific Optometry, P. C. 健 視 眼 科 中 心 219 Grand St. (& Elizabeth St.) 格 蘭 街 219 號 ( 夾 伊 利 沙 白 街 ) New York, NY 電 話 :(212) (212) FLUSHING 法 拉 盛 Flushing Optical 永 昌 眼 鏡 公 司 Main Street 緬 街 號 Flushing, NY 電 話 :(718) (718) Hunter Vision Center Inc. 華 埠 眼 鏡 公 司 Main Street 緬 街 號 Flushing, NY 電 話 :(718) (718)

3 Davis Vision 戴 維 斯 視 覺 服 務 中 心 ( 新 澤 西 ) BERGEN BERGEN OPTOMETRY GROUP 348 MAIN ST HACKENSACK, NJ (201) DR ANN P. HIGGINS 299 FOREST AVE (201) DR BURNETT EGLOW 219 BOULEVARD HASBROUCK HTS, NJ (201) DR FRANK J. DEGEORGE 103 UNION ST LODI, NJ (973) DR JACK L. GOLDBERG 1562 LEMOINE AVENUE FORT LEE, NJ (201) DR JAMES M. SINOWAY 400 FRANKLIN AVE WYCKOFF, NJ (201) DR JEROME SWIRSON JORDAN ROAD FAIR LAWN, NJ (201) DR MARC WEINER 64 RIDGE RD NORTH ARLINGTON, NJ (201) DR MARIA I. CARDONA 299 FOREST AVE SUITE E (201) DR MARK RUDERMAN 28 EAST PALISADE AVE (201) DR MICHAEL J. YELLEN 185 BROADWAY HILLSDALE, NJ (201) DR NICHOLAS J. THEISZ 223 OLD HOOK RD WESTWOOD, NJ (201) DR NORMAN E. OPAS 679 ANDERSON AVE CLIFFSIDE PARK, NJ (201) DR PAUL BERMAN 5 SUMMIT AVENUE SUITE 4 HACKENSACK, NJ (201) DR ROBERT SC PURNELL 31 PARK AVENUE RUTHERFORD, NJ (201) DR ROSEMARY FRASCO 1 W. RIDGEWOOD AVE (201) DR STEVEN J. SEIDEL 12 E PALISADE AVE (201) EYE TO EYE VISION CENTER GARDEN STATE PLAZA RT 4 & RT 17 (201) JEANINE E GRAVES OD 11-11RIVER RD FAIR LAWN, NJ (201) MY VISION CARE CORP LEMOINE AVE STE 5 FORT LEE, NJ (201) THE NJ INSTITUTE OF OPHTHALMOLOGY 106 GRAND AVE 4TH FLR (201) HUDSON VISION 1516 SUMMIT AVE (201) DR CLETTA A. ROCHESTER 2 HIGHLAND AVE (201) DR EDWARD MASLANSKY 399 KEARNY AVE KEARNY, NJ (201) DR ELIZABETH S. GARITA 64 SIP AVE (201) Wednesday, April 05, 20 Page 1 of 3

4 DR HAROLD J. DAVIS 548 BROADWAY BAYONNE, NJ (201) EYE EXAMINATION CENTER 3400 BERGENLINE AVE (201) OPTICAL PALACE II 461 CENTRAL AVE (201) DR JACK GOLDSTEIN TH ST (201) DR JACK GOLDSTEIN TH ST (201) DR JOSELYN L. ESTEVEZ ST ST (201) DR MADELINE L. ROMEU 6408 BERGENLINE AVENUE WEST NEW YORK, NJ (201) DR MARK D. HECHT 550 SUMMIT AVENUE (201) DR ROBERT J FREED 9003 BERGENLINE AVE (201) DR SAVOY & SIEGEL 127 NEWARK AVENUE JERSEY CITY, NJ (201) DR THOMAS OKANE 2877 KENNEDY BLVD (201) DR WILLIAM C. FRUCHTMAN 3 MILLCREEK DR. #69 SECAUCUS, NJ (201) EYE EXAMINATION CENTER 3400 BERGENLINE AVE (201) EYESITE 1108 WASHINGTON ST HOBOKEN, NJ (201) FREED VISION CENTER 1301 PATERSON PLANK RD SECAUCUS, NJ (201) HARBORSIDE OPTICAL HARBORSIDE FINANCIAL CENTER PLAZA 2 JERSEY CITY, NJ (201) HEALTHEXCEL PROFESSIONAL CORP 3196 KENNEDY BLVD 2ND FLOOR (201) HUDSON EYECARE ASSOCIATES, P.A. 368 CENTRAL AVE JERSEY CITY, NJ (201) MORGANSTEIN EYE ASSOC LLC 5618 BERGENLINE AVE PO BOX 449 WEST NEW YORK, NJ (201) NOBEL OPTICAL 701 ROUTE 440 INSIDE HUDSON MALL JERSEY CITY, NJ (201) OPTICAL PALACE 910 BERGEN AVE (201) R.M. VISION- EYE CONTACT CENTER 7733 BERGENLINE AVE (201) TAMAR KALLUS, O.D BERGENLINE AVE (201) MIDDLESEX DAVIS VISION WORKS 4105 RTE 1 SUITE 7 MONMOUTH JCTN, NJ (732) DR ARNOLD GLICKMAN 127 LIVINGTON AVE (732) DR BRUCE D. KASTNER 6 DUNDEE AVE ISELIN, NJ (732) DR DAVID WEININGER 177 EASTON AVE (732) DR JOEL ROSE 1510 PARK AVE (908) DR LOWELL S. DAVIS 1030 ST GEORGES AVE AVENEL, NJ (609) DR MICHAEL F. SCHWARTZ 94 SMITH ST PERTH AMBOY, NJ (732) Wednesday, April 05, 20 Page 2 of 3

5 DR RICHARD H. FRANKEL 343 WASHINGTON RD SAYREVILLE, NJ (732) DR RUSSELL S. KATEMAN 100 MAIN ST WOODBRIDGE, NJ (732) DR STEPHEN ROSENBERG 778 RTE 1 N N. BRUNSWICK, NJ (732) EYE FIRST VISION CENTER OAKTREE RD EDISON, NJ (732) EYEKRAFTERS OPTICAL 911 OAKTREE RD (908) EYES WIDE OPEN OPTICAL 415 RT 18 VILLAGE GREEN EAST BRUNSWICK, NJ (732) EYESTYLES OF WOODBRIDGE 1030 ST. GEORGE AVENUE AVENEL, NJ (732) IN FOCUS VISION CENTER 1100 CENTENNIAL AVE STE 102 PISCATAWAY, NJ (732) MONROE VISION ASSOCIATES 365 SPOTSWOOD-ENGLISHTOWN RD MONROE TOWNSHIP, NJ (732) MONROE VISION ASSOCIATES 337 APPLEGARTH RD MONROE TOWNSHIP, NJ (609) OPTICAL VIEW 400 RENAISSANCE BLVD N. BRUNSWICK, NJ (732) OPTICAL VIEW II PROSPECT ST MID STATE MALL E BRUNSWICK, NJ (732) PATEL EYE ASSOCIATES 228 PLAINFIELD AVE EDISON, NJ (732) FAMILY EYE CARE AND CONTACT LENSES 400 RENAISSANCE BLVD (732) HEALTHEXCEL PROF CORP 906 OAKTREE RD OAKTREE BUSINESS CENTER SUITE J (908) HEALTHY EYES VISION SERVICES 776 AMBOY AVE CLARA BARTON PROFESSIONAL BLDG EDISON, NJ (732) Wednesday, April 05, 20 Page 3 of 3

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