General Forms
All States Provider Address Form
All States W-9
On-Line Eye Health Manager Request Form
Claims Appeal Request Form
Claims Status Request Form
Fee Schedules
Panel Participation Request Form
Waiver of Liability Form
Texas Pre-Authorization Request
Pre-Authorization Request
Prior Notification Form
Advanced Beneficiary Notice (ABN)
Provider Update Form
Non-Covered Services Liability Acknowledgement
UPMC Health Plan Non-Covered Services Agreement

Submission of credentialing materials does not guarantee the processing or approval of your participation with OptiCare Managed Vision / AECC-Total Vision Health Plan of Texas, Inc.  All submitted materials will be reviewed and responded to accordingly.