Georgia Medicaid Vision Forms
If you are interested in participating in this new Medicaid program, you must have, or obtain, a Georgia Medicaid Provider Identification number.
Each form is available in (PDF) format
for you to print or download at your convenience.
National Provider Identifier (NPI) Application:
Providers across all specialty lines are required to complete a NPI application. If you have not already done so, click this link to be connected to the National Plan & Provider Enumeration System (NPPES) web site. Get Form
Avesis Provider Application:
Providers new to Avesis or who have not completed an application within the past three years should complete a new application. Get Form
Vision Provider Agreement:
The Provider Agreement outlines the contractual arrangement between "the provider" and Avesis. Get Form
Vision Authorization Form:
Prior Approval Form to be completed and submitted to Avesis in order to obtain authorization for services such as cataract co-management, medically necessary contact lenses, vision therapy, and replacement glasses. Get Form
Non-covered Services:
Enrollees of Georgia Medicaid do have the option of buying up for services or materials. Anytime enrollees has an out-of-pocket responsibility to a provider, the Non-covered Services form must be completed and retained as a permanent part of the patient file.
Get Form
Option 1 Frame Inventory Form:
Providers selecting Option 1, the delivery of eyeglasses from their own inventory, must complete, submit to Avesis and keep current this inventory form. Get Form
Georgia Correction Industries (GCI) Eyeglass Order Form:
Providers who select Option 2, GCI are required to use this form to place their orders.
Get Form
Essilor Provider Application:
Providers utilizing Option 3, Essilor, for the delivery of materials to eligible enrollees of Georgia Medicaid must complete and return to Essilor an account application. Get Form
Essilor/Southern Optical Eyeglass Order Form:
Providers who selected Option 3, Essilor are required to use this form to place their orders. Get Form
Electronic Funds Transfer (EFT):
EFT is available to providers on this panel who are utilizing electronic mediums for eligibility verification and claims submission. Get Form
Credentialing Checklist:
Details all required credentialing materials to be submitted to Avesis. Get Form
Provider Election Form
Select from three vision benefits program options for the Georgia Medicaid program.
Get Form
Send Completed Materials by mail or fax to Provider Services
Mail To:
Avesis Third Party AdministratorsAttn: Provider Services
P.O. Box 782
Owings Mills, MD 21117