N C Vision - Eye Care Benefit Form

Benefits Form

To receive the discounts provided in the N.C. Vision Health Plan you will need to present a Benefits Authorization Form when you arrive at your appointment.
Please fill out the form below and submit your information. You will then be directed to a link to download and print your personalized form.

Fields marked with an * are required.

Benefit Plan Type *

Individual

Group Plan Name *

Name *

Email Address *

Address1 *

Address2

City *

State *

Zip *

Telephone

Current Eye Care Provider

Employer/Association

Promo Code from Provider (optional)

Enter the code below *