OUT-OF-NETWORK CLAIM FORM

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FRAUD WARNING STATEMENTS
Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents afalse or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false,
incomplete, or misleading information may be prosecuted under state law.
Arkansas: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
California: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or
fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purposeof defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to apolicyholder or claimant for the purpose of defrauding or attempting to defraud a policyholder or claimant with regard to a settlement oraward payable from insurance proceeds shall be reported to the Colorado Department of Insurance within the department of regulatoryagencies.
District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding theinsurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
contain ing any false, incomplete or misleading information is guilty of a felony of the third degree.
Georgia: Any person who knowingly, and with intent to defraud any insurance company, files a statement of claim containing any false,incomplete or misleading information may be subject to criminal penalties.
Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is acrime punishable by fines or imprisonment, or both.
Idaho: Any person who knowingly and with intent to defraud or deceive any insurance company, files a statement or claim containing afalse, incomplete or misleading information is guilty of a felony.
Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete or
misleading information commits a felony.
Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application or claim forinsurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent act, which is a crime.
Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose ofdefrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement inprison.
Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing
any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in § 638.20.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal andcivil penalties.
New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
New York: Any person who knowingly and with intent to defraud insurance company or other person files an application for insurance or
sta-te ment of claim containing any materially false information or conceals for the purpose of misleading, information concerning any factmaterial thereto, commits a fraudulent act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the statedvalue of the claim for each such violation.
Ohio: Any person who, with intent to defraud, or knowing that he is facilitating a fraud against an insurer, submits an application or false
claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer makes any claim for theproceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject tofines and confinement in state prison.
Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose ofdefrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

OUT-OF-NETWORK CLAIM FORM

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CLAIMS MAILING ADDRESSES
VSPP.O. Box 997105
Sacramento, CA 95899-7105
DAVIS VISION CARE PROCESSING UNIT

P.O. Box 1525
Latham, NY 12110

SPECTERA CLAIMS DEPARTMENT

P. O. Box 26618
Baltimore, MD 21207-6618