Vision Care Claim Form (3585A) – WSIB in Ontario

The Vision Care Claim Form (3585A) is used for submitting claims related to vision care to the Workplace Safety and Insurance Board (WSIB). The form also includes instructions for signing and submitting, with options to either type the name and upload or print and sign before returning to WSIB.

Follow these steps to complete the form accurately:

Section A: Worker Information

Claim Number

1. • Enter the claim number provided by WSIB.

Personal Details:

1. • Last Name: Enter your last name.
   • First Name: Enter your first name.
   • Initial: Enter your middle initial, if any.
   • Current Address: Write your full current address.
   • City: Enter the city you reside in.
   • Province: Enter the province you reside in.
   • Postal Code: Enter your postal code.
   • Is this a new address? Check ‘yes’ if this is a new address, otherwise check ‘no’.

Contact Information

1. • Home Phone: Enter your home phone number.
   • Work Phone: Enter your work phone number.
   • Birth Date (mm/dd/yyyy): Enter your date of birth in the format month/day/year.

Section B: Provider Information

Provider Details

1. • Provider Name: Write the name of your vision care provider.
   • Address: Write the full address of the provider.
   • City: Enter the city of the provider’s address.
   • Province: Enter the province of the provider’s address.
   • Postal Code: Enter the postal code of the provider’s address.
   • Business Phone: Enter the business phone number of the provider.

Stamp or Label: Attach the provider’s stamp or label if available.

Section C: Damage for Repair/Replacement Entitlement

To be completed by the provider:

Lens and Frame Details

1. • Single Vision Lens(es): Check ‘yes’ if applicable, otherwise check ‘no’.
   • Hardex Lens(es): Check ‘yes’ if applicable, otherwise check ‘no’.
   • Tint: Check ‘yes’ if applicable, otherwise check ‘no’.
   • Other (specify type): Specify the type if other lenses are used.
   • Bifocal (specify type): Specify the type if bifocal lenses are used.

Prescription Information

1. • Right Eye (OD): Enter the prescription details for the right eye.
   • Left Eye (OS): Enter the prescription details for the left eye.

Damage Information

1. • Was there damage done to the lenses? Check ‘left’, ‘right’, ‘both’, or ‘none’ as applicable.
   • Was there damage done to the frame? Check ‘yes’ or ‘no’.

Replacement Information

1. • Is the replacement frame similar to the damaged frame? Check ‘yes’ or ‘no’.
   • If not, is it of equal value? Check ‘yes’ or ‘no’.

Cost Information

1. • Cost of Original Frames: Enter the cost of the original frames.
   • Cost of Replacement Frames: Enter the cost of the replacement frames.
   • Cost of Original Lens(es): Enter the cost of the original lenses.
   • Cost of Replacement Lens(es): Enter the cost of the replacement lenses.
   • Total Cost: Enter the total cost the worker paid and is requesting reimbursement for.

Provider Signature and Date: The provider must sign and date this section.

Section D: Prescription Information

To be completed by the optometrist if vision entitlement exists:

Prescription Types and Details

1. • New Prescription: Indicate if it’s a new prescription.
   • Contact Lenses: Indicate if it’s for contact lenses.
   • Replacement: Indicate if it’s a replacement due to loss or breakage.
   • Right Eye: Enter the prescription details for the right eye.
   • Left Eye: Enter the prescription details for the left eye.
   • Old RX: Enter the old prescription details if applicable.

Medical Conditions: Indicate any medical conditions or diseases relevant to the prescription.

Visual Acuity Information

1. • Indicate if the visual acuity can be restored or improved.
   • Type of Lenses: Specify the type of right and left lenses.
   • Tint and Oversize: Indicate if the lenses have tint or are oversized.

Provider Signature and Date: The optometrist must sign and date this section.

Section E: Worker Declaration

Certification and Authorization:

1. • Declaration: Read the declaration carefully.
   • Signature: Sign and date the form to certify that the information provided is true and accurate.

Submission Instructions

Mail To: Send the completed form to WSIB, 200 Front Street West, Toronto ON M5V 3J1.

• Fax To: You can also fax the form to 416-344-4684 or 1-888-313-7373.
• Contact: For any questions, contact WSIB at 416-344-1000 or toll-free at 1-800-387-0750. TTY users can call 1-800-387-0050.

Make sure to retain all original receipts and provide them with this form. For expenses paid by WSIB, do not request reimbursement from other insurers or organizations.