Forms – Vision Plan of America

Forms

Online Forms

Submit forms online or download PDF versions for members, group administrators, brokers, and providers.

For Members — Online Forms

Grievance Form

Use this form if you wish to report a complaint with Vision Plan of America regarding your membership.

Grievance Form (Spanish) / Proceso de Queja

Use esta forma si necesita hacer una queja con Vision Plan of America sobre su plan de visión.

Status Change Form

Use this form to make changes to your membership (name/address, provider, dependents, etc.).

Status Change Form (Spanish) / Cambio de Estado

Use esta forma si necesita hacer cambios a su membresía.

Demographic Profile Update

Add or update demographic information to your member profile (optional).

Demographic Profile Update (Spanish)

Actualización del Perfil Demográfico (opcional).

Quality Improvement Survey

Tell us about your experience with your provider.

For Group Administrators — Online Forms

Status Change Form

Make changes to a group member's coverage.

Downloadable Forms and Documents

PDF versions of plan brochures and forms.

Individual Plans

4 Plan Brochure

Schedule of Extras

Full Service Plans (Schedule of Extras)

Co-Pay Plans (Schedule of Extras)

Dental Benefits — Best Choice Plan

Dental Benefits — Emerald Plan

Provider Directories

Vision Providers Directory

Dental Providers Directory

For Members

Cancellation Form

Cancel your membership with Vision Plan of America.

Grievance Form

Report a complaint regarding your membership.

Grievance Form (Spanish) / Proceso de Queja

Hacer una queja sobre su plan de visión.

Status Change Form

Make changes to your membership.

Status Change Form (Spanish) / Cambio de Estado

Hacer cambios a su membresía.

MNCL Public Disclosure

MNCL Public Disclosure (Spanish)

For Group Administrators

Vision and Dental Employee Enrollment Form

Vision Employee Enrollment Form

Status Change Form

Make changes to a member's coverage.

Knox-Keene licensed specialized vision HMO — serving California since 1986

800-400-4872

Online Forms

For Members — Online Forms

Grievance Form

Grievance Form (Spanish) / Proceso de Queja

Status Change Form

Status Change Form (Spanish) / Cambio de Estado

Demographic Profile Update

Demographic Profile Update (Spanish)

Quality Improvement Survey

For Group Administrators — Online Forms

Status Change Form

Downloadable Forms and Documents

Individual Plans

4 Plan Brochure

Schedule of Extras

Full Service Plans (Schedule of Extras)

Co-Pay Plans (Schedule of Extras)

Dental Benefits — Best Choice Plan

Dental Benefits — Emerald Plan

Provider Directories

Vision Providers Directory

Dental Providers Directory

For Members

Cancellation Form

Grievance Form

Grievance Form (Spanish) / Proceso de Queja

Status Change Form

Status Change Form (Spanish) / Cambio de Estado

MNCL Public Disclosure

MNCL Public Disclosure (Spanish)

For Group Administrators

Vision and Dental Employee Enrollment Form

Vision Employee Enrollment Form

Status Change Form

For Vision Providers

Sample Provider Contract

Links