Vision - Marion County Public Schools

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Vision - Marion County Public Schools
2012 ENROLLMENT
Marion County Public Schools
Vision summary of benefits
Vision Member services • 800-865-3676
www.compbenefits.com/custom/marioncounty/
HSBVIS2010
NEW08191070195
visioncare plan
What to expect from your vision plan:
Your eyesight is nothing to take for granted. It’s how we see a loved one’s face
clearly or a beautiful sunset.
But your sight can begin to deteriorate over a long period of time without your
knowing there is a problem.
As with any other important asset – like your home or car – wouldn’t you feel
more at ease if you knew your routine eye care was covered by a company with
decades experience helping people like you? With CompBenefits’ VisionCare
Plan, you can take advantage of coverage you need for eye examinations and
eyeglasses or contacts.
You can also choose to take advantage of VisionCare Plan’s deep discount for
LASIK surgery.
And you won’t have to hunt hard to find a doctor close to your home or work.
The VisionCare Plan network includes some 14,000 ophthalmologist and
optometrist locations – one third of all private practitioners in the country. Yet,
it doesn’t mean you can’t see an out-of-network doctor because VisionCare Plan
offers benefits in-network or out-of-network. It’s your choice.
You’ll find what you need
@ www.mycompbenefits.com
CompBenefits has made understanding and accessing your VisionCare Plan
benefits simple. Just take a few moments to register at www.mycompbenefits.com.
SSVCP
No claims to file!
Just show your
VisionCare Plan
ID card
Marion County Public Schools
Open your eyes to high-quality vision care! The average family spends close to $600 each year on routine eye health
care. Using CompBenefits’ VisionCare Plan, you will receive your routine eye health care with just a small
copayment.
CompBenefits’ VisionCare Plan provides benefits for covered:
Eye health examinations
Frames
Eyeglass Lenses
Contact Lenses
Plus you will receive:
LASIK surgery discount
Preferred member pricing for other frame and lens options*
When ordering from one of our network eye doctors, you will also receive in the year of your eye exam:
A 20% discount on a second pair of eyeglasses
A 15% discount on your contact lens fitting fee
PER
PAYPERIOD
RATES
Employee only:
Employee + family:
$ 3.59
$10.28
SERVICE FREQUENCY
Vision exam:
Lenses:
Frame:
Once every 12 months
Once every 12 months
Once every 24 months
COPAYMENTS
Exam:
Materials:
$10
$15
SAVINGS! SEE THE DIFFERENCE
You can save money two ways with VisionCare. First, the cost of plan services and materials is discounted and prepaid.
So except for any co-payments, you have no out-of-pocket expenses for covered services and supplies when you use
one of our network doctors. Second, your coverage costs are deducted from your pay before any federal income or
FICA taxes are taken out. This makes your taxable wage base lower, so you would pay less tax.
Here’s an example of how the plan helps you save over the course of a year:
If You Get:
Eye exam
Frame (designer style)
Lenses: Bifocal
Option (pink tint #1 or #2)
Co-payments:
$10 exam/$15 materials
Premium ($3.59 per payperiod x 20)
You Pay:
VisionCare
Doctor
Typical
Retail
.00
.00
.00
.00
$ 85.00
120.00
100.00
15.00
$ 25.00
+ 71.80
.00
.00
96.80
$ 320.00
Pre-tax savings (assuming 15% tax
bracket & 7.65% FICA)
- 16.26
+
Total Cost
$80.54
$ 320.00
.00
YOUR TOTAL SAVINGS THROUGH VISIONCARE: 75% OFF RETAIL
In this example, you would have saved $239.46 in vision care costs with VisionCare Plan. Keep in mind, however, that
your actual savings will depend on your plan allowances, your actual premium, the doctors and materials you select,
and your own tax situation.
* This is not a schedule of maximum benefits. For example, the plan covers frames based on the manufacturer’s wholesale price guide. So while the
retail price of a covered frame may vary among plan doctors, the value of your covered frame stays the same. Typically, the wholesale frame allowance
is equivalent to a retail price of $80-120. You may be required to pay extra only if you choose a frame that exceeds the covered wholesale price.
Maximum Allowances
Participating Doctor
(After copayments/
Up to plan limits)
* This allowance is paid with the same frequency as
lenses, in place of all other benefits.
Single
Paid in full
** Medically necessary (prior authorization required) i s
defined as 1) following cataract surgery w/o intraocular
lens; 2) correction of extreme visual acuity problems not
correctable with glasses; 3) anisometropia greater than
5.00 diopters and asthenopia or diplopia, with spectacles;
4) Keratoconus; or 5) monocular aphakia and/or binocular
aphakia where the doctor certifies contact lenses are
medically necessary for safety and rehabilitation to a
productive life.
Bifocal
Paid in full
*** Plan members must first contact CompBenefits for a list
of providers and to receive a Refractive Care ID card.
Trifocal
Paid in full
Lenticular
Paid in full
Eye Exam
Paid in full
Lenses (per pair)
Contact Lenses
Elective
This schedule shows only a few of the covered
procedures. Please see your Benefit Administrator for a
complete schedule. This schedule is intended for
comparison purposes only. The benefits of each plan will
be determined by the contract. For a complete listing of
benefits and exclusions and limitations, please reference
your certificate of coverage.
(fitting, follow-up & lenses)
$150*
Out-of-network benefits apply under the VisionCare Plan,
but benefits are higher when a participating doctor i s
utilized.
Medically necessary**
Paid in full
Limitations and Exclusions apply.
Frame
$40 wholesale
Lasik***
Members receive benefits when services are received from a TLC Truvision network
provider with the following preferred rates:
• Silver Package: $895/eye for Conventional LASIK
• Gold Package: $1,295/eye for CustomLASIK
• Platinum Package: $1,895/eye for CustomLASIK plus
Bladeless LASIK (using IntraLase technology).
Members will also receive a 10% discount off UCR charges at other preferred LASIK
provider locations, and pay no more than $1,800 per eye for the Conventional LASIK
procedure and $2,300 per eye for CustomLASIK.
HOW DOES VISIONCARE PLAN WORK?
Members simply select any in-network optometrist or ophthalmologist and schedule an appointment. You can locate a
provider in your area by accessing the current directory online at www.mycompbenefits.com.
The Plan is simple to use. Select a doctor from our provider directory and call for an appointment. At the time of your
appointment, present your ID Card to the participating provider. Members will pay only their co-payments and for any
extra cosmetic options selected. There are no additional forms to complete or claims to file.
Members can also choose an out-of-network provider. In this case, you will pay the doctor at the time of the visit and
submit receipts to Compbenefits for reimbursement.
CAN I GET CONTACTS INSTEAD OF LENSES?
Yes. If you prefer contacts instead of glasses, your vision exam is covered-in-full with your exam co-payment and
VisionCare Plan provides a generous allowance of $150.00 to be applied towards your fitting and follow-up fees as well
as materials costs. The Contact Lens allowance in LIEU OF THE LENS / FRAME BENEFIT and is provided with the same
frequency as your lens benefit.
HOW DO I GET FURTHER QUESTIONS ANSWERED?
You may contact CompBenefits Customer Care Department with any questions or concerns at: 1-800-865-3676,
Monday – Thursday 8am-8pm; and Friday 8am-6pm EST. or locate us on the web at www.mycompbenefits.com.
frequently asked questions
Q. What are CompBenefits’ VisionCare Plans?
A. CompBenefits’ VisionCare Plans are network-based vision plans that emphasize high quality routine
eye health care from independent eye care professionals. Services and materials are provided on a
pre-paid basis, and the plans pay network doctors directly. VisionCare Plan members can also use
non-network doctors if they wish.
Q.
How does VisionCare Plan work?
A. Members simply select any in-network optometrist or ophthalmologist and make their appointments.
At the time of the appointment, members pay only their co-payments and for any extra cosmetic options
selected. There are no forms to complete or claims to file.
Members can also choose an out-of-network provider. In this case, they pay their doctor at the time
of the visit and submit receipts to CompBenefits for reimbursement. Benefits are paid according to a
reimbursement schedule.
Q.
Are there any limitations to my vision benefit?
A. Yes, there are a few. Oversized lenses, when prescribed, may be covered only when patient’s face size
indicates they are necessary. Blended and progressive lenses are not normally required for visual
welfare and are generally excluded. Elective or cosmetic items such as photochromic lenses, fashion
color-coated lenses and sun lenses are not normally covered.
Q.
Does VisionCare Plan exclude anything?
A. Yes, some items and services are excluded.
• Orthoptics or vision training, subnormal vision aids or plano (non-prescription) lenses
• Replacement of lost or broken lenses, except at the regularly-scheduled plan intervals
• Medical or surgical treatment of the eyes
• Care provided through or required by any government agency or program,including Workers’
Compensation or similar law
Q.
What do I need to access my benefits?
A. It’s simple. Just take your VisionCare Plan ID card to your eye doctor, and he or she will file your claim
for you.
Q.
Can I go online to find out more about my plan or get assistance?
A. Yes. You can visit www.mycompbenefits.com to learn about your plan, to check your benefits, to use our
Provider Locator, to send us an e-mail and more.
See the difference a bigger, better
HumanaVision network can make for you.
HumanaVision VCP has a newly expanded network. Choose from
more than 35,000 participating optometrist, ophthalmologist, and
national retail locations, including LensCrafters, Pearle Vision, Sears
Optical, Target Optical, and JCPenney.
HumanaVision offers:
• Cost-Savings — Your benefits for eyewear apply at even more HumanaVision
provider locations. And you’ll pay the same cost for frames no matter where you go.
• Choice — You now have access to exclusive lines of designer frames, such as
Dolce & Gabbana®, Oakley ®, Prada®, Ralph Lauren®, and Ray-Ban®.
• Convenience — Take care of eye exams and frames all in one visit. Many locations
offer night and weekend appointments to fit your schedule.
HumanaVisionCare.com
Finding a provider is easy.
Call Customer Care at 1-866-537-0229
or go to HumanaVisionCare.com.
To offer the widest choice, HumanaVision also includes independent optometrists
and ophthalmologists located throughout the country. For a complete listing of
providers near you, visit humanavisioncare.com.
Looking for a great pair of glasses to fit your unique personality and lifestyle?
LensCrafters is the right place for you. You can choose from a wide selection of
fashion frames including the latest designers like Prada®, Versace®, Burberry ®, and
Dolce & Gabbana®. Add the latest lens technology for that great pair of glasses.
More than 850 locations nationwide. Visit lenscrafters.com for the latest styles
and trends and your nearest location.
Pearle Vision continues the legacy of personalized eye care that Dr. Stanley Pearle
started over 45 years ago. Combine that with a great selection of frames and lens
options and over 750 convenient locations to make Pearle Vision a great place for
your family’s eye care. Go to pearlevision.com to learn more.
Sears Optical has been helping families see better and look great at the right price
for over 45 years. Everything you love and trust about Sears is what you’ll find
at Sears Optical — professional service, stylish selection of frames and the latest
contact lens advancements, quality, and great value for the entire family. Satisfaction
guaranteed or your money back. More than 850 Sears Optical locations are
conveniently located nationwide. Visit searsoptical.com for one near you.
Your eyes. Your style. Target Optical provides fashion for less than you’ve come
to expect from Target, with the care of a professional independent doctor of
optometry. You can choose from a huge selection of frames and sunglasses, including
brands like Mossimo®, Vogue®, and Versus®. The latest contact lens technology is also
available at affordable prices. Visit target.com for more information.
JCPenney Optical is a full-service optical center conveniently located in more
than 350 JCPenney department stores. Choose from hundreds of frames that will
inspire and reflect your lifestyle, including exclusive designer brands such as Bisou
Bisou®, a.n.a.®, Liz & Co.®, and Arizona®. JCPenney Optical also offers eye exams,
contact lenses, and non-prescription sunwear to meet all of your eyewear needs.
Insured by Humana Insurance Company, CompBenefits Insurance Company, CompBenefits of HumanaDental Insurance Company,
CompBenefits Company, or The Dental Concern, Inc.
GCA0AV3HH 4/11
Vision Provider Directory
Alachua, Bradford, Citrus, Flagler, Gilchrist, Lake, Levy, Marion, Putnam, Sumter, and Volusia Counties
The providers listed in this brochure were participating with the plan at the time of printing. Please check with the doctor of your choice or call our Customer Care department at 1-800-749-5855 when making your
appointment to make certain he or she is currently a member doctor. You may also visit our website at www.compbenefits.com for a nationwide listing of providers.
You must receive services from one of our participating providers in order to receive full benefits (as outlined in your vision care booklet). If you receive service from a provider who does not participate in the plan, you
will receive reimbursement according to the non-panel reimbursement schedule established by your group.
ALACHUA
Alachua
Larry J LaTour OD PA
LaTour, OD, Larry J
15551 NW US Hwy 441 Unit 110
32615 (386)462-7772
Gainesville
Dr Mark Raymond Watson PA
Lange Eye Care & Associates
Pieschke, OD, Glenn D
3968 SW Archer Rd Ste W-101
32608 (352)376-6622
Lange Eye Care & Associates
Ramsay, OD, William K
3968 SW Archer Rd Ste W-101
32608 (352)376-6622
Lange Eye Care & Associates
Watson, OD, Mark R
1800 NE 12th Ave
32641 (904)589-8512
Rodriguez, OD, Alexis
3968 SW Archer Rd Ste W-101
32608 (352)376-6622
Dr Tost and Associates
Lange Eye Care & Associates
Pearle Vision
Pearle Vision
Pearle Vision
Pearle Vision
Pearle Vision
Quinn Eye Center
Frick, OD, Susan M
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Joly, OD, Sandra D
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Kershner, OD, Jesse B
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Tost, OD, Gary L
3654 SW Archer Rd
32608 (352)264-0385
Schramm, OD, Nathan H
3968 SW Archer Rd Ste W-101
32608 (352)376-6622
Gainesville Eye Physicians Pa
Lange Eye Care & Associates
Hazouri, MD, Gerald G
716 E University Ave
32601 (352)376-4479
Sicard, OD, Laurie A
3968 SW Archer Rd Ste W-101
32608 (352)376-6622
Kirchner, OD, Bradley S
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Gainesville Vision Center PA
Lenscrafters
Pearle Vision
Cooke, OD, Russell Y
6667 W Newberry Rd
Oaks mall
32605 (352)332-0744
Mutai, OD, Christopher K
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Lenscrafters
Pearle Vision
Harp, OD, Lisa M
6667 W Newberry Rd
Oaks mall
32605 (352)332-0744
Olsen, OD, Susan K
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Lenscrafters
Pearle Vision
Deputy, OD, Gerald R
4401 NW 25th Pl Ste D
32606 (352)335-3937
John T Beckum OD
Beckum, OD, John T
2216 NW 40th Ter Ste B
32605 (352)376-1288
Jose Arnao OD PA
Arnao, OD, Jose
6757 W Newberry Rd
32605 (352)331-2040
JC Penney Optical
Optical, JC Penney
6481 W Newberry Rd
32605 (352)332-8643
JC Penney Optical
Tesinsky, OD, Kenneth J
6481 W Newberry Rd
32605 (352)332-8643
JC Penney Optical
Vazoulas, OD, George L
6481 W Newberry Rd
32605 (352)332-8643
Lange Eye Care & Associates
Abraham, OD, Julie
3968 SW Archer Rd Ste W-101
32608 (352)376-6622
Lange Eye Care & Associates
Atkins, OD, Brian R
3968 SW Archer Rd Ste W-101
32608 (352)376-6622
Lange Eye Care & Associates
Hernandez, OD, Madeline
3968 SW Archer Rd Ste W-101
32608 (352)376-6622
Lange Eye Care & Associates
Lange, OD, Michael P
3968 SW Archer Rd Ste W-101
32608 (352)376-6622
Lange Eye Care & Associates
McClintic Jr, OD, Virgil M
3968 SW Archer Rd Ste W-101
32608 (352)376-6622
Pearle Vision
Lenscrafters #454, Lenscrafter
6667 W Newberry Rd
Oaks mall
32605 (352)332-0744
Rubin, OD, Jack
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Lenscrafters
Pearle Vision
Miller, OD, Joe E
6667 W Newberry Rd
Oaks mall
32605 (352)332-0744
Tabatabai, OD, Ali
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Lenscrafters
Pearle Vision
Shaw, OD, Steven M
6667 W Newberry Rd
Oaks mall
32605 (352)332-0744
Taylor, OD, Jamie L
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Lenscrafters
Pearle Vision
Strucko, OD, Nadia L
6667 W Newberry Rd
Oaks mall
32605 (352)332-0744
Thiele, OD, Scott L
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Pearle Vision
Pearle Vision
Ball, OD, Walter L
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Tucker, OD, Tiffany D
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Pearle Vision
Pearle Vision
Blalock, OD, Jeffrey S
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Villa, OD, Carlos R
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Pearle Vision
Pearle Vision
Brink, OD, Theodore M
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Vision, Pearle
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Walker, OD, Jon S
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Wygonik, OD, Edward S
6405 W Newberry Rd
Oaks mall
32605 (352)331-6321
Quinn, OD, R. K
817 NW 56th Ter Ste B
32605 (352)331-7771
Sears Optical
Optical, Sears
6201 W Newberry Rd
Oaks mall
32605 (352)331-8650
Sears Optical
Phillips, OD, Barry D
6201 W Newberry Rd
Oaks mall
32605 (352)331-8650
Sears Optical
Phillips, OD, Susan B
6201 W Newberry Rd
Oaks mall
32605 (352)331-8650
Starling Eye Group
Starling, OD, Heather M
4635 NW 53rd Ave Ste 202
32653 (352)333-9971
Super Optical Express
Buckner, OD, John M
6757 W Newberry Rd
6757 West Newberry Road
32605 (352)331-2040
Super Optical Express
Funderburk, OD, Paul E
6757 W Newberry Rd
32605 (352)331-2040
Super Optical Express, Inc
Deputy, OD, Gerald
6757 W Newberry Rd
32605 (352)331-7627
University Opticians Inc
Barber, OD, Jon L
300 SW 4th Ave
32601 (352)378-4480
CITRUS
Beverly Hills
Beverly Hills Eye Clinic
Newcomer, OD, Jay D
3636 N Lecanto Hwy
34465 (352)746-0800
Crystal River
Crystal Eye Center And optical
Dawson, OD, Thomas W
1124 N Suncoast Blvd
34429 (352)795-3317
July, 2011
Homosassa
Eye Doctors Optical Outlets
Stamp, OD, Thomas
3944 S Suncoast Blvd # 5
34448 (352)621-7528
Eye Doctors Optical Outlets
Weisbond, OD, Steven M
3944 S Suncoast Blvd # 5
34448 (352)621-7528
Homosassa Eye Clinic
Newcomer, OD, Annemarie
4564 S Suncoast Blvd
34446 (352)628-3029
Inverness
Lange Eye Care & Associates
Abraham, OD, Julie
3808 E Gulf To Lake Hwy
34453 (352)344-5110
Lange Eye Care & Associates
Atkins, OD, Brian R
3808 E Gulf To Lake Hwy
34453 (352)344-5110
Lange Eye Care & Associates
Hernandez, OD, Madeline
3808 E Gulf To Lake Hwy
34453 (352)344-5110
Lange Eye Care & Associates
Lange, OD, Michael P
3808 E Gulf To Lake Hwy
34453 (352)344-5110
Lange Eye Care & Associates
McClintic Jr, OD, Virgil M
3808 E Gulf To Lake Hwy
34453 (352)344-5110
Lange Eye Care & Associates
Pieschke, OD, Glenn D
3808 E Gulf To Lake Hwy
34453 (352)344-5110
Lange Eye Care & Associates
Ramsay, OD, William K
3808 E Gulf To Lake Hwy
34453 (352)344-5110
Lange Eye Care & Associates
Schramm, OD, Nathan H
3808 E Gulf To Lake Hwy
34453 (352)344-5110
Lange Eye Care & Associates
Sicard, OD, Laurie
3808 E Gulf To Lake Hwy
34453 (352)344-5110
Suncoast Optical
Singh, OD, Navindra S
3351 E Gulf To Lake Hwy
34453 (352)637-4000
Victor T Nothnagel OD pa
Target Optical
Optical, Target
5100 E Highway 100
32164 (386)586-7924
Target Optical
Rivera, OD, Michelle L
5100 E Highway 100
32164 (386)586-7924
Target Optical
Weiss, OD, Amanda
5100 E Highway 100
32164 (386)586-7932
Target Optical
Weiss, OD, Amanda L
5100 E Highway 100
32164 (386)586-7932
Tomoka Eye Associates
Kennedy, MD, Mark E
21 Hospital Dr Ste 160
32164 (386)586-3711
Tomoka Eye Associates
Kline, OD, Thomas M
21 Hospital Dr Ste 160
32164 (386)586-3711
Tomoka Eye Associates
Makowski, MD, Michael K
21 Hospital Dr Ste 160
32164 (386)586-3711
Tomoka Eye Associates
Root, MD, Timothy D
21 Hospital Dr Ste 160
32164 (386)586-3711
Tomoka Eye Associates
Schoeler, OD, Karin L
21 Hospital Dr Ste 160
32164 (386)586-3711
Total Vision of Palm Coast
Chalker, OD, Bonnie M
15 Cypress Branch Way Ste 205
32164 (386)445-1880
Total Vision of Palm Coast
Chih, OD, Andreea
15 Cypress Branch Way Ste 205
32164 (386)445-1880
Total Vision of Palm Coast
Coughlin, OD, Sean P
15 Cypress Branch Way Ste 205
32164 (386)445-1880
Total Vision of Palm Coast
Stephens, OD, Phillip L
15 Cypress Branch Way Ste 205
32164 (386)445-1880
LAKE
Clermont
Clermont Optical and Vision Ce
Harless, OD, Heather A
2332 Highway 44 W
34453 (352)726-2085
Fusselman, OD, John K
231 Citrus Tower Blvd
34711 (352)243-2700
Victor T Nothnagel OD pa
Eye Specialists of Mid-Florida
Nothnagel, OD, Victor T
2332 Highway 44 W
34453 (352)726-2085
FLAGLER
Palm Coast
Eyecare Express
Lind, OD, Kris E
110 Palm Coast Pkwy NE
32137 (386)446-1200
Target Optical
Choat, OD, Christopher R
5100 E Highway 100
32164 (386)586-7932
Burry, OD, David N
1050 US Highway 27 Ste 1
34714 (352)394-8705
Eye Specialists of Mid-Florida
Fisher, OD, Alan P
1050 US Highway 27 Ste 1
34714 (352)394-8705
Eye Specialists Of Florida pa
Aziz-Toppino, MD, Mayssa
1715 E Highway 50
Ste A Bldg 3
34711 (352)243-8704
Eye Specialists Of Florida pa
Toler, OD, Allison R
1715 E Highway 50
Ste A Bldg 3
34711 (352)243-8704
James R Davis Iv od
Davis, OD, James R
730 7Th St
34711 (352)394-6168
McCoy Vision Center
McCoy, OD, David J
3140 Citrus Tower Blvd Ste B
34711 (352)243-2121
Optical Heaven
Lascaibar, OD, Albert A
231 Citrus Tower Blvd
34711 (352)243-2700
Premier Ophthalmology
Flud, DO, Jacqueline K
3195 Citrus Tower Blvd
34711 (352)241-9700
South Lake Optical
Smith, OD, Gray R
2250 E Highway 50 Ste 1
34711 (352)243-5349
Target Optical
Optical, Target
2660 E Highway 50
34711 (352)394-3521
Target Optical
Toler, OD, Allison R
2660 E Highway 50
34711 (352)394-3521
Eustis
Central Florida Eye Ctr
Gatson, OD, Kenneth C
2303 S Bay St
32726 (352)357-1027
Central Florida Eye Ctr
Verkaik, OD, Kristine G
2303 S Bay St
32726 (352)357-1027
Lady Lake
Albert R Ducharme OD PA
Ducharme, OD, Albert R
1128 Bichara Blvd
32159 (352)750-2414
Eye Doctors Optical Outlets
Barber, OD, Jon L
574 N US Highway 441
32159 (352)350-5298
Eye Doctors Optical Outlets
Orr, OD, Dionne C
574 N US Highway 441
32159 (352)350-5298
Eye Doctors Optical Outlets
Raney, OD, Dennis B
574 N US Highway 441
32159 (352)350-5298
Eye Doctors Optical Outlets
Schugar, OD, Richard E
574 N US Highway 441
32159 (352)350-5298
James K Berry OD PA
Berry, OD, James K
1128 Bichara Blvd
32159 (352)750-2414
Leesburg
Albert R Ducharme OD
Ducharme, OD, Albert R
1320 Shelfer St
34748 (352)728-1700
Drs Williams & Vihlen pa
Vihlen, OD, Fredrick S
112 E Dixie Ave
34748 (352)787-1956
Drs Williams & Vihlen pa
Williams, OD, Samuel W
112 E Dixie Ave
34748 (352)787-1956
Eye Doctors Optical Outlets
Barber, OD, Jon L
10601 US Highway 441 Ste C17
34788 (352)360-0051
Eye Doctors Optical Outlets
Johannessen, OD, Karl D
10601 US Highway 441 Ste C17
34788 (352)360-0051
Eye Doctors Optical Outlets
Kay, OD, Jordan M
10601 US Highway 441 Ste C17
34788 (352)360-0051
Eye Doctors Optical Outlets
Ma, OD, Chunfeng
10601 US Highway 441 Ste C17
34788 (352)360-0051
Eye Doctors Optical Outlets
Raney, OD, Dennis B
10601 US Highway 441 Ste C17
34788 (352)360-0051
Eye Doctors Optical Outlets
Schugar, OD, Richard E
10601 US Highway 441 Ste C17
34788 (352)360-0051
James K Berry OD PA
Berry, OD, James K
1320 Shelfer St
34748 (352)787-9799
JC Penney Optical
Ness, OD, David R
10401 US Highway 441 Ste 2001
34788 (352)787-0027
JC Penney Optical
Optical, JC Penney
10401 US Highway 441 Ste 2001
34788 (352)787-0027
Pearle Vision
Milovac, OD, Carl L
10401 US Highway 441 Ste 334
Lake square mall
34788 (352)787-7170
Pearle Vision
Vision, Pearle
10401 US Highway 441 Ste 334
Lake square mall
34788 (352)787-7170
Mount Dora
Mid Florida Eye Center
Helman, OD, Lori M
17560 US Highway 441
32757 (352)735-2020
Mid Florida Eye Center
Higuera, OD, Victor A
17560 US Highway 441
32757 (352)735-2020
Mid Florida Eye Center
Jones, OD, Brian W
17560 US Highway 441
32757 (352)735-2020
Mid Florida Eye Center
Shorr, OD, Jack N
17560 US Highway 441
32757 (352)735-2020
DRS RITZ AND JOHNSON
Lange Eye Care & Associates
Optical Express
DRS RITZ AND JOHNSON
Lange Eye Care & Associates
Ritz Eyecare
Lange Eye Care & Associates
Eye Doctors Optical Outlets
Chai, OD, Sook K
3100 SW College Rd Ste 582A
34474 (352)237-5569
Lange Eye Care & Associates
Ritz Eyecare
Abraham, OD, Julie
125 SW 7th St
32696 (352)528-4033
Lange Eye Care & Associates
Eye Doctors Optical Outlets
Orr, OD, Dionne C
3100 SW College Rd Ste 582A
34474 (352)237-5569
Lange Eye Care & Associates
Ritz Eyecare
Atkins, OD, Brian R
125 SW 7th St
32696 (352)528-4033
Lange Eye Care & Associates
Eye Doctors Optical Outlets
Raney, OD, Dennis B
3100 SW College Rd Ste 582A
34474 (352)237-5569
Lange Eye Care & Associates
Sears Optical
Hernandez, OD, Madeline
125 SW 7th St
32696 (352)528-4033
Lange Eye Care & Associates
Eye Doctors Optical Outlets
Lange Eye Care & Associates
LEVY
Chiefland
Michael A Rascati OD pa
Rascati, OD, Michael A
1117 NW 19th Ave
32626 (352)493-2180
Williston
Ritz, OD, N W
150 SE 17th St Ste 100
34471 (352)732-7900
Willeford, OD, Scott K
150 SE 17th St Ste 100
34471 (352)732-7900
Lange, OD, Michael P
125 SW 7th St
32696 (352)528-4033
Schugar, OD, Richard E
3100 SW College Rd Ste 582A
34474 (352)237-5569
Lange Eye Care & Associates
I-Care Vision Center
McClintic Jr, OD, Virgil M
3101 SW College Rd Ste 101
34474 (352)237-3768
Pieschke, OD, Glenn D
11100 SW 93rd Court Rd Ste 15
34481 (352)291-2000
Pieschke, OD, Glenn D
3101 SW College Rd Ste 101
34474 (352)237-3768
Ramsay, OD, William K
11100 SW 93rd Court Rd Ste 15
34481 (352)291-2000
Ramsay, OD, William K
3101 SW College Rd Ste 101
34474 (352)237-3768
Rodriguez, OD, Alexis
11100 SW 93rd Court Rd Ste 15
34481 (352)291-2000
Lange Eye Care & Associates
Collins, OD, Paul
6290 SW Highway 200
34476 (352)237-6200
Ritz, OD, Daniel L
6290 SW Highway 200
34476 (352)237-6200
Ritz, OD, N W
6290 SW Highway 200
34476 (352)237-6200
Optical, Sears
3100 SW College Rd Ste 300
Paddock mall
34474 (352)873-5269
Sears Optical
Phillips, OD, Barry D
3100 SW College Rd Ste 300
Paddock mall
34474 (352)873-5269
McClintic Jr, OD, Virgil M
125 SW 7th St
32696 (352)528-4033
Singh, OD, Navindra S
3101 SW 34th Ave Ste 201
34474 (352)854-3088
Lange Eye Care & Associates
JC Penney Optical
Pieschke, OD, Glenn D
125 SW 7th St
32696 (352)528-4033
Miller, OD, Joe E
3100 SW College Rd Ste 100
34474 (352)237-4151
Lange Eye Care & Associates
Lange Eye Care & Associates
JC Penney Optical
Ramsay, OD, William K
125 SW 7th St
32696 (352)528-4033
Optical, JC Penney
3100 SW College Rd Ste 100
34474 (352)237-4151
Lange Eye Care & Associates
Zanetti, OD, Gene V
2050 E Silver Springs Blvd
34470 (352)629-3009
Lange Eye Care & Associates
JC Penney Optical
Lange Eye Care & Associates
Rodriguez, OD, Alexis
125 SW 7th St
32696 (352)528-4033
Vazoulas, OD, George L
3100 SW College Rd Ste 100
34474 (352)237-4151
Lange Eye Care & Associates
Lange Eye Care & Associates
Lange Eye Care & Associates
Schramm, OD, Nathan H
125 SW 7th St
32696 (352)528-4033
Abraham, OD, Julie
11100 SW 93rd Court Rd Ste 15
34481 (352)291-2000
Lange Eye Care & Associates
Lange Eye Care & Associates
Sicard, OD, Laurie A
125 SW 7th St
32696 (352)528-4033
MARION
Belleview
Ritz Eyecare
Collins, OD, Paul
5215 SE Abshier Blvd
34420 (352)245-9000
Ritz Eyecare
Ritz, OD, Daniel L
5215 SE Abshier Blvd
34420 (352)245-9000
Ocala
Abraham, OD, Julie
3101 SW College Rd Ste 101
34474 (352)237-3768
Lange Eye Care & Associates
Atkins, OD, Brian R
11100 SW 93rd Court Rd Ste 15
34481 (352)291-2000
Lange Eye Care & Associates
Atkins, OD, Brian R
3101 SW College Rd Ste 101
34474 (352)237-3768
Lange Eye Care & Associates
Hernandez, OD, Madeline
11100 SW 93rd Court Rd Ste 15
34481 (352)291-2000
Rodriguez, OD, Alexis
3101 SW College Rd Ste 101
34474 (352)237-3768
Anderson, OD, Paul E
600 SW 10th St Ste 104
34471 (352)629-7509
Schramm, OD, Nathan H
11100 SW 93rd Court Rd Ste 15
34481 (352)291-2000
Schramm, OD, Nathan H
3101 SW College Rd Ste 101
34474 (352)237-3768
Sicard, OD, Laurie A
11100 SW 93rd Court Rd Ste 15
34481 (352)291-2000
Lange Eye Care & Associates
Sicard, OD, Laurie A
3101 SW College Rd Ste 101
34474 (352)237-3768
Lenscrafters
Cooke, OD, Russell Y
2701 SW College Rd
Gaitway plaza
34474 (352)237-3788
Lenscrafters
Harp, OD, Lisa M
2701 SW College Rd
Gaitway plaza
34474 (352)237-3788
Lenscrafters
Lenscrafters #840, Lenscrafter
2701 SW College Rd
Gaitway plaza
34474 (352)237-3788
Lenscrafters
Dr Richard K Clark
Lange Eye Care & Associates
Clark, OD, Richard K
810 NE 25th Ave
34470 (352)732-0046
Hernandez, OD, Madeline
3101 SW College Rd Ste 101
34474 (352)237-3768
Shahi, OD, Sanjeet K
2701 SW College Rd
Gaitway plaza
34474 (352)237-3788
DRS RITZ AND JOHNSON
Lange Eye Care & Associates
Lenscrafters
Cheney, OD, Jerry
150 SE 17th St Ste 100
34471 (352)732-7900
Lange, OD, Michael P
11100 SW 93rd Court Rd Ste 15
34481 (352)291-2000
DRS RITZ AND JOHNSON
Lange Eye Care & Associates
Johnson, OD, Ray H
150 SE 17th St Ste 100
34471 (352)732-7900
Lange, OD, Michael P
3101 SW College Rd Ste 101
34474 (352)237-3768
Lange Eye Care & Associates
McClintic Jr, OD, Virgil M
11100 SW 93rd Court Rd Ste 15
34481 (352)291-2000
Shaw, OD, Steven M
2701 SW College Rd
Gaitway plaza
34474 (352)237-3788
Lenscrafters
Strucko, OD, Nadia L
2701 SW College Rd
Gaitway plaza
34474 (352)237-3788
Sears Optical
Phillips, OD, Susan B
3100 SW College Rd Ste 300
Paddock mall
34474 (352)873-5269
Vision World
Summerfield
Abraham, OD, Julie
16770 S US Highway 441 Ste 604
34491 (352)307-3273
Lange Eye Care & Associates
Atkins, OD, Brian R
16770 S US Highway 441 Ste 604
34491 (352)307-3273
Lange Eye Care & Associates
Hernandez, OD, Madeline
16770 S US Highway 441 Ste 604
34491 (352)307-3273
Lange Eye Care & Associates
Lange, OD, Michael P
16770 S US Highway 441 Ste 604
34491 (352)307-3273
Lange Eye Care & Associates
McClintic Jr, OD, Virgil M
16770 S US Highway 441 Ste 604
34491 (352)307-3273
Lange Eye Care & Associates
Pieschke, OD, Glenn D
16770 S US Highway 441 Ste 604
34491 (352)307-3273
Lange Eye Care & Associates
Ramsay, OD, William K
16770 S US Highway 441 Ste 604
34491 (352)307-3273
Lange Eye Care & Associates
Rodriguez, OD, Alexis
16770 S US Highway 441 Ste 604
34491 (352)307-3273
Lange Eye Care & Associates
Schramm, OD, Nathan H
16770 S US Highway 441 Ste 604
34491 (352)307-3273
Lange Eye Care & Associates
Sicard, OD, Laurie A
16770 S US Highway 441 Ste 604
34491 (352)307-3273
Mid Florida Eye Center
Higuera, OD, Victor A
17556 SE 109th Terrace Rd
34491 (352)347-2100
Mid Florida Eye Center
Jones, OD, Brian W
17556 SE 109th Terrace Rd
34491 (352)347-2100
Mid Florida Eye Center
Shorr, OD, Jack N
17556 SE 109th Terrace Rd
34491 (352)347-2100
PUTNAM
Palatka
Palatka Vision Center
Miles, OD, Charles S
3424 Saint Johns Ave
32177 (386)328-4456
Palatka Vision Center
Miles, OD, David E
3424 Saint Johns Ave
32177 (386)328-4456
Palatka Vision Center
Miles, OD, Henry E
3424 Saint Johns Ave
32177 (386)328-4456
Palatka Vision Center
Miles, OD, William F
3424 Saint Johns Ave
32177 (386)328-4456
St Johns Eye Care
Deputy, OD, Gerald R
2504 Crill Ave
32177 (386)328-5141
St Johns Eye Care
Lennon Jr., OD, John M
2504 Crill Ave
32177 (386)328-5141
Lange Eye Care & Associates
Lange, OD, Michael P
11834 County Road 101
32162 (352)753-4014
Lange Eye Care & Associates
McClintic Jr, OD, Virgil M
11834 County Road 101
32162 (352)753-4014
Lange Eye Care & Associates
Pieschke, OD, Glenn D
11834 County Road 101
32162 (352)753-4014
Lange Eye Care & Associates
Ramsay, OD, William K
11834 County Road 101
32162 (352)753-4014
Lange Eye Care & Associates
Rodriguez, OD, Alexis
11834 County Road 101
32162 (352)753-4014
Lange Eye Care & Associates
Schramm, OD, Nathan H
11834 County Road 101
32162 (352)753-4014
Lange Eye Care & Associates
Sicard, OD, Laurie A
11834 County Road 101
32162 (352)753-4014
Wildwood
Jack Sperry OD
Sperry, OD, Jack N
349 Shopping Center Dr
34785 (352)330-2200
VOLUSIA
Daytona Beach
SUMTER
Bushnell
Daytona Eye Center
Sperry, OD, Jack N
940 N Main St
33513 (352)568-0442
Florida Eye Care Laser & Catar
Brostko, OD, Sarah L
1814 W C 48
33513 (352)568-0600
Florida Eye Care Laser & Catar
Kaufman, MD, Stuart J
1814 W C 48
33513 (352)568-0600
Florida Eye Care Laser & Catar
Lin, MD, Selina J
1814 W C 48
33513 (352)568-0600
Florida Eye Care Laser & Catar
Parker, OD, Timothy A
1814 W C 48
33513 (352)568-0600
The Villages
Lange Eye Care & Associates
Abraham, OD, Julie
11834 County Road 101
32162 (352)753-4014
Lange Eye Care & Associates
Atkins, OD, Brian R
11834 County Road 101
32162 (352)753-4014
Lange Eye Care & Associates
Hernandez, OD, Madeline
11834 County Road 101
32162 (352)753-4014
Deputy, OD, Gerald R
1700 W Intl Spwy Blvd Ste 200
Volusia mall
32114 (386)254-5239
Sears Optical
Broome Jr., OD, Frank A
701 S Ridgewood Ave
32114 (386)253-5999
Daytona Eye Center
Broome, OD, Erin C
701 S Ridgewood Ave
32114 (386)253-5999
Daytona Eye Center
Broome, OD, Kevin A
701 S Ridgewood Ave
32114 (386)253-5999
Daytona Eye Center
Case, OD, John Michael
701 S Ridgewood Ave
32114 (386)253-5999
Daytona Eye Center
Owusu, OD, Nana Y
701 S Ridgewood Ave
32114 (386)253-5999
Daytona Eye Center
Phipps, OD, Renee G
701 S Ridgewood Ave
32114 (386)253-5999
Daytona Eye Center
Toffoli, OD, Nicholas J
701 S Ridgewood Ave
32114 (386)253-5999
Robert R Young Md
Young, MD, Robert R
163 E Intl Spdwy Blvd
32118 (386)253-4207
Orange City
Eye Savers
Barnard, OD, Horatio Thomas
2564 Enterprise Rd
32763 (386)774-7242
Optical, Sears
1700 W Intl Spwy Blvd Ste 200
Volusia mall
32114 (386)254-5239
Eye Savers
Sears Optical
Eye Savers
Toscano, OD, Philip G
1700 W Intl Spwy Blvd Ste 200
Volusia mall
32114 (386)254-5239
Vision One Inc
Haynes, OD, Michael L
1900 Mason Ave Ste 100
32117 (386)274-5525
Vision One Inc
Kipp, OD, Gregory T
1900 Mason Ave Ste 100
32117 (386)274-5525
Debary
Jay Ananthan-Nair OD
Ananthan-Nair, OD, Jayakumar
38 N Beall Blvd
32713 (386)668-0600
Ramey, OD, Dustin H.
Ramey, OD, Dustin H
2836 Enterprise Rd Ste 3
32713 (386)668-8885
Ramey, OD, Dustin H.
Wilgers, OD, Kirsten R
2836 Enterprise Rd Ste 3
32713 (386)668-8885
Daytona Eye Center
Barnard, OD, Horatio Thomas
701 S Ridgewood Ave
32114 (386)253-5999
Durham Optical
Sears Optical
Deland
Total Vision
Heacock, OD, Charles E
840 N Stone St
32720 (386)734-1766
Total Vision
Timko, OD, Jeffrey L
840 N Stone St
32720 (386)734-1766
Vision One Corp
Haynes, OD, Michael L
801 N Stone St
32720 (386)734-4431
Deltona
Jay Ananthan-Nair OD
Ananthan-Nair, OD, Jayakumar
1308 E Normandy Blvd Ste D
32725 (386)860-3812
New Smyrna Beach
Beach Vision Ctr
Register, OD, Charles D
1928 State Road 44
32168 (386)423-7788
Timko and Cady OD PA
Chalker, OD, Bonnie M
330 Canal St
32168 (386)423-5190
Timko and Cady OD PA
Chih, OD, Andreea
330 Canal St
32168 (386)423-5190
Timko and Cady OD PA
Stephens, OD, Phillip L
330 Canal St
32168 (386)423-5190
Broome Jr., OD, Frank A
2564 Enterprise Rd
32763 (386)774-7242
Broome, OD, Erin C
2564 Enterprise Rd
32763 (386)774-7242
Eye Savers
Broome, OD, Kevin A
2564 Enterprise Rd
32763 (386)774-7242
Eye Savers
Case, OD, John Michael
2564 Enterprise Rd
32763 (386)774-7242
Eye Savers
Owusu, OD, Nana Y
2564 Enterprise Rd
32763 (386)774-7242
Eye Savers
Phipps, OD, Renee G
2564 Enterprise Rd
32763 (386)774-7242
Eye Savers
Toffoli, OD, Nicholas J
2564 Enterprise Rd
32763 (386)774-7242
Florida Eye Clinic Pa
Jochum, MD, James M
787 Health Care Dr
32763 (386)668-4332
Florida Eye Clinic Pa
Steedle, MD, Thomas O
787 Health Care Dr
32763 (386)668-4332
Gateway Vision
Burgess, OD, Burl R
2576 S Volusia Ave Ste 102
32763 (386)774-6000
George C Beckwith OD
Beckwith, OD, George C
177 N Industrial Dr
32763 (386)574-1411
Pearle Vision
Uong, OD, Sokonviset
1039 Harley Strickland Blvd
West volusia town ctr
32763 (386)774-0321
Pearle Vision
Vision, Pearle
1039 Harley Strickland Blvd
West volusia town ctr
32763 (386)774-0321
Ormond Beach
Elite Eyecare
Ling, OD, Edward G
1185 W Granada Blvd Ste 7
32174 (386)676-3937
Eye Savers
Broome Jr., OD, Frank A
1474 W Granada Blvd Ste 470
32174 (386)673-3011
Eye Savers
Broome, OD, Erin C
1474 W Granada Blvd Ste 470
32174 (386)673-3011
Eye Savers
Tomoka Eye Associates
Eye Savers
Tomoka Eye Associates
Eye Savers
Tomoka Eye Associates
Eye Savers
Tomoka Eye Associates
Eye Savers
Tomoka Eye Associates
Eye Savers
Tomoka Eye Associates
Eye Savers
Tomoka Eye Associates
Eye Savers
Total Vision of Port Orange
Eye Savers
Tomoka Eye Associates
Eye Savers
Total Vision of Port Orange
Florida Eye Clinic Pa
Tomoka Eye Associates
Eye Savers
Total Vision of Port Orange
Target Optical
Vision One Inc
Target Optical
Vision One Inc
Tomoka Eye Associates
Vision One Inc
Broome, OD, Kevin A
1474 W Granada Blvd Ste 470
32174 (386)673-3011
Case, OD, John Michael
1474 W Granada Blvd Ste 470
32174 (386)673-3011
Owusu, OD, Nana Y
1474 W Granada Blvd Ste 470
32174 (386)673-3011
Phipps, OD, Renee G
1474 W Granada Blvd Ste 470
32174 (386)673-3011
Toffoli, OD, Nicholas J
1474 W Granada Blvd Ste 470
32174 (386)673-3011
Cady, OD, Michael T
1089 W Granada Blvd Ste 4
32174 (386)676-1300
Kennedy, MD, Mark E
345 Clyde Morris Blvd Ste 330
32174 (386)672-4244
Kline, OD, Thomas M
345 Clyde Morris Blvd Ste 330
32174 (386)672-4244
Makowski, MD, Michael K
345 Clyde Morris Blvd Ste 330
32174 (386)672-4244
Root, MD, Timothy D
345 Clyde Morris Blvd Ste 330
32174 (386)672-4244
Schoeler, OD, Karin L
345 Clyde Morris Blvd Ste 330
32174 (386)672-4244
Spertus, MD, Alan D
345 Clyde Morris Blvd Ste 330
32174 (386)672-4244
Florida Eye Clinic Pa
Jochum, MD, James M
1089 W Granada Blvd Ste 4
32174 (386)676-1300
Jay A Keesling OD PA
Keesling, OD, Jay A
1425 Hand Ave Ste A
32174 (386)673-2020
Jay A Keesling OD PA
Waite, OD, George W
1425 Hand Ave Ste A
32174 (386)673-2020
Port Orange
Blahnik Eye Care Inc
Blahnik, OD, Gregory F
3740 S Ridgewood Ave Unit 103
32129 (386)492-7946
Blahnik Eye Care Inc
Blahnik, OD, Suzette A
3740 S Ridgewood Ave Unit 103
32129 (386)492-7946
Eye Savers
Broome Jr., OD, Frank A
3781 S Nova Rd Ste O
32129 (386)760-8626
Broome, OD, Erin C
3781 S Nova Rd Ste O
32129 (386)760-8626
Broome, OD, Kevin A
3781 S Nova Rd Ste O
32129 (386)760-8626
Case, OD, John Michael
3781 S Nova Rd Ste O
32129 (386)760-8626
Owusu, OD, Nana Y
3781 S Nova Rd Ste O
32129 (386)760-8626
Phipps, OD, Renee G
3781 S Nova Rd Ste O
32129 (386)760-8626
Toffoli, OD, Nicholas J
3781 S Nova Rd Ste O
32129 (386)760-8626
Optical, Target
1771 Dunlawton Ave
32127 (386)304-7360
Weiss, OD, Amanda L
1771 Dunlawton Ave
32127 (386)304-7360
Kline, OD, Thomas M
790 Dunlawton Ave Ste A
32127 (386)767-0053
Root, MD, Timothy D
790 Dunlawton Ave Ste A
32127 (386)767-0053
Schoeler, OD, Karin L
790 Dunlawton Ave Ste A
32127 (386)767-0053
Spertus, MD, Alan D
790 Dunlawton Ave Ste A
32127 (386)767-0053
Chalker, OD, Bonnie M
5820 S Williamson Blvd Ste 106
32128 (386)767-4449
Chih, OD, Andreea
5820 S Williamson Blvd Ste 106
32128 (386)767-4449
Wilgers, OD, Kirsten R
5820 S Williamson Blvd Ste 106
32128 (386)767-4449
Haynes, OD, Michael L
3820 S Nova Rd
32127 (386)767-0068
Kipp, OD, Gregory T
3820 S Nova Rd
32127 (386)767-0068
Toscano, OD, Philip G
3820 S Nova Rd
32127 (386)767-0068
Marion County Public Schools
Benefits Enrollment Form
Please complete the following information:
Social Security No.
Last Name
First
Home Address
Middle
Date of Birth
Home Phone
City
State
ZIP Code
Gender
Business Phone
List All Your Eligible Dependents That Are To Be Covered
First
MI
Last
Sex
Spouse:
Child:
Child:
Child:
Child:
Child:
Child:
Effective Date:
PLEASE CHECK
YOUR CHOICE
Plan Code:
Group Number
Birth Date
M
F
/
/
M
F
/
/
M
F
/
/
M
F
/
/
M
F
/
/
M
F
/
/
M
F
/
/
Your E-mail Address
Agent Number
207063
Vision Plan
Per Pay Period Rates
Employee Only
Employee + Family
$3.
$10.
I wish to enroll in the plan indicated above as offered through my employer. I understand that this is a minimum one (1)
year contract. I hereby authorize my employer to deduct all applicable contribution amounts from my salary or other
compensation for the plan year, and for future renewal period(s). I understand that such contribution rate is subject to
change on the anniversary date of the plan.
I hereby represent that all information furnished by me hereon is true and complete to the best of my knowledge.
Signature: X _____________________________________________________ Date: ____________________
2010 ENROLLMENT
Marion County Public Schools
Vision summary of benefits
Vision Customer Care • 800-865-3676
www.compbenefits.com/custom/marioncounty/
HSBVIS2010
NEW082911

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