CUSTOMER SERVICE REQUEST FOR DELTAVISION® PROGRAMS

     
 

We take every precaution to protect the confidentiality of your request, especially sensitive information such as social security numbers. For more information, see our Web privacy notice.

 
   
  • If you wish to obtain eligibility and benefits information, please complete the form below.

  • If you are looking for vision provider, please use the DeltaVision Directory.
  • If you wish to file a complaint, please do not enter it here. Instead, we would like the opportunity to personally resolve your issue and discuss the information we will need to investigate your complaint. Please contact us at 1-888-963-6576, or use our Enrollee Grievance Form.

 
Individual Information
Fields noted with an asterisk (*) are required.
       
Enrollee First Name*    
Enrollee Last Name*    
Enrollee ID*    
New Name (if applicable)    
     
Enrollee Date of Birth* / / (mm/dd/yyyy)    
Street Address*    
City*    
State*    
ZIP Code* -    
E-mail Address*    
Phone Number ( ) - Fax Number ( ) -
Please check here if this is a new address.
 
Requested Action
Please check the appropriate areas below that apply to your request.
Be sure to first provide your name, e-mail address and enrollee ID number above.
Please verify my/my family's eligibility for vision coverage.
I would like a description of my vision benefits (Evidence of Coverage/Disclosure).
I would like an additional Identification Card.
I am requesting a transfer to a different vision office.
Office provider number you wish to transfer to: **
 
** NOTE: The vision office number is located at the top of each record in the printed and online directories. The transfer will be effective on the first of the following month if the request is received by the 21st of the month. Treatment in progress must be completed by the attending vision provider before a transfer to a new office is approved.
 
Other question or request.
Please state your question clearly and fully. Do not use this to file a complaint. See top of this form for more information.

 
   
       
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If you prefer to mail or telephone your inquiry, you can reach us at:

DeltaVision Customer Service
P.O. Box 1803
Alpharetta, GA 30023
Toll-free
(888) 963-6576

Fax
(562) 809-7059

       
 
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