Insurance Cloud Additions

The template below MUST be completed along with any other pertinent information. Eyefinity reserves the right to approve, decline or change requests based on business needs. Please be aware Eyefinity may be contacting you for a copy of the Insurance Card (Front and Back) to complete a request.

All fields are required unless noted.

Customer Information

Practice Name

Submitter Name

Submitter Email

Practice Phone

Carrier Information

Refer to TriZetto/GatewayEDI's Payer List

(NOTE: Payer ID’s from non-TriZetto clearing houses cannot be integrated).

TriZetto Payer ID

Website (if applicable)

Carrier Name

Address 1

Address 2 (if applicable)

City

State

Zip

Phone

Fax (optional)

Coverage Type

Vision Medical Vision & Medical

Authorization Required

Yes No

Medicaid Plan

Yes No

Additional Information (optional)

Submit