standard-title Forms

Forms

Online Forms

For Members

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 vision

Status Change Form
Use this form if you wish to make changes to your membership (such as change of name/address, change of provider, add/delete dependents, etc.)

Status Change Form (Spanish)/Cambio de Estado
Use esta forma si necesita hacer cambios a su membresía. (Por Ejemplo: Cambio de Nombre/Domicilio, Cambio de Proveedor, Agregar/Cancelar Dependientes, etc.)

Demographic Profile Update Form
Use this form if you wish to add or update your demographic information to your member profile (optional)

Demographic Profile Update Form (Spanish)/Actualización del Perfil Demográfico
Use este formulario si desea agregar o actualizar su información demográfica a su perfil de miembro (opcional)

For Group Administrators

Status Change Form
Use this form if you wish to make changes to your membership (such as change of name/address, change of provider, add/delete dependents, etc.)

Downloadable Forms and Documents

Individual Plans

4 Plan Brochure

Schedule of Extras

Full Service Plans
Co-Pay Plans
Dental Benefits – Best Choice Plan
Dental Benefits – Emerald Plan

Provider Directories

Vision Providers Directory
Dental Providers Directory

For Members

Cancellation Form
Use this form if you wish to cancel your membership with Vision Plan of America

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 vision

Status Change Form
Use this form if you wish to make changes to your membership (such as change of name/address, change of provider, add/delete dependents, etc.)

Status Change Form (Spanish)/Cambio de Estado
Use esta forma si necesita hacer cambios a su membresía. (Por Ejemplo: Cambio de Nombre/Domicilio, Cambio de Proveedor, Agregar/Cancelar Dependientes, etc.)

MNCL Public Disclosure

MNCL Public Disclosure (Spanish)

For Group Administrators

Vision and Dental Employee Enrollment Form

Vision Employee Enrollment Form

Status Change Form
Use this form if you wish to make changes to your membership (such as change of name/address, change of provider, add/delete dependents, etc.)

For Vision Providers

Sample Provider Contract