MyACUVUE® REWARDS MAIL IN SUBMISSION FORM
COMPILE the following documents to complete your submission.
This submission form (completed)
Copy of your receipt showing Eye Care Professional's name, patient name, ACUVUE® Brand purchased, quantity purchased, purchase date and purchase price. Please ensure all information is legible.
MAIL all documents to:
HelloWorld, Inc.
PO Box 5085
Kalamazoo MI 49003-5085
By submitting my information, I agree that Johnson & Johnson Vision Care, Inc., may use it to evaluate my Rewards Submission and to contact me about this program, and that it will be governed by the Johnson & Johnson Vision Care, Inc., Privacy Policy (https://www.acuvue.com/privacy-policy).
I have read the Full Terms and Conditions. Reward requests must be received within 60 days of purchase.
CONTACT INFORMATION
All fields required. Please print clearly.
EMAIL ADDRESS
MOBILE PHONE
Physical gift card (if selected) will be shipped to this address.
SHIPPING ADDRESS (NO P.O. BOXES, PLEASE.)
BIRTH DATE (MM/DD/YYYY)
PURCHASE DETAILS
REWARDS CODE
(From the Promotional Page provided by your Eye Care Professional)
EYE CARE PROFESSIONAL (First and Last Name)
NAME ON PRESCRIPTION
SELECT YOUR ACUVUE® BRAND
Please mark the left (L) eye and right (R) eye brand corresponding to your purchase.
ACUVUE® VITA® ACUVUE OASYS® 2-Week
ACUVUE OASYS® 2-Week for ASTIGMATISM ACUVUE OASYS® 2-Week for PRESBYOPIA ACUVUE OASYS® 1-Day with HYDRALUXE™ Technology ACUVUE OASYS® 1-Day for ASTIGMATISM
1-DAY ACUVUE® MOIST
1-DAY ACUVUE® MOIST for ASTIGMATISM
1-DAY ACUVUE® MOIST Brand MULTIFOCAL
1-DAY ACUVUE® TruEye®
1-DAY ACUVUE® DEFINE®
SELECT THE QUANTITY PURCHASED
See next page for number of boxes required for each reward.
Please mark the left (L) eye and right (R) eye box corresponding to your purchase.

1 Box (12 Lenses per Box)

1 Box (24 Lenses per box)

1 Box (90 Lenses per Box)

2 Boxes (6 Lenses per box)

2 Boxes (12 Lenses per box)

2 Boxes (24 Lenses per box)

2 Boxes (90 Lenses per box)

3 Boxes (30 Lenses per Box)

4 Boxes (6 Lenses per box)

4 Boxes (12 Lenses per box)

4 Boxes (90 Lenses per box)

6 Boxes (30 Lenses per box)

8 Boxes (6 Lenses per box)

8 Boxes (90 Lenses per box)

12 Boxes (30 Lenses per box) 
24 Boxes (30 Lenses per box)
Page 1 of 2
Page 2 of 2
Available Rewards
ACUVUE OASYS® Brand |
$ |
|
$ |
|
$ |
1Day for ASTIGMATISM |
200 |
|
75 |
|
10 |
|
ANNUAL SUPPLY |
6 MONTH SUPPLY |
3 MONTH SUPPLY |
|
24 boxes (30 Lenses per Box) |
12 boxes (30 Lenses per Box) |
6 boxes (30 Lenses per Box) |
|
|
|
|
|
|
ACUVUE OASYS® Brand |
$ |
|
$ |
|
$ |
1Day with HydraLuxe™ Technology |
200 |
|
75 |
|
10 |
|
ANNUAL SUPPLY |
6 MONTH SUPPLY |
3 MONTH SUPPLY |
|
8 boxes (90 Lenses per Box) |
4 boxes (90 Lenses per Box) |
2 boxes (90 Lenses per Box) |
|
|
|
|
|
|
1DAY ACUVUE® TruEye® Brand |
|
|
|
|
|
Contact Lenses |
|
|
|
|
|
1DAY ACUVUE® MOIST Brand |
$120 |
$50 |
|
$10 |
Contact Lenses |
|
1DAY ACUVUE® MOIST Brand |
|
MULTIFOCAL |
ANNUAL SUPPLY |
6 MONTH SUPPLY |
3 MONTH SUPPLY |
1DAY ACUVUE® MOIST Brand |
8 boxes (90 Lenses per Box) |
4 boxes (90 Lenses per Box) |
2 boxes (90 Lenses per Box) |
24 boxes (30 Lenses per Box) |
12 boxes (30 Lenses per Box) |
6 boxes (30 Lenses per Box) |
for ASTIGMATISM |
|
|
|
|
|
1DAY ACUVUE® DEFINE® Brand |
|
|
|
|
|
Contact Lenses |
|
|
|
|
|
|
|
|
|
|
|
ACUVUE OASYS® Brand |
$55 |
|
|
$10 |
2Week for ASTIGMATISM |
|
|
ACUVUE OASYS® Brand |
ANNUAL SUPPLY |
|
6 MONTH SUPPLY |
2Week for PRESBYOPIA |
8 boxes (6 Lenses per Box) |
|
4 boxes (6 Lenses per Box) |
|
|
|
|
ACUVUE OASYS® Brand |
$40 |
|
$10 |
Contact Lenses 2Week |
ANNUAL SUPPLY |
|
6 MONTH SUPPLY |
|
2 boxes (24 Lenses per Box) |
|
1 box (24 Lenses per Box) |
|
4 boxes (12 Lenses per Box) |
2 boxes (12 Lenses per Box) |
|
|
|
|
|
|
ACUVUE® VITA® |
$ |
|
|
$ |
|
Brand Contact Lenses |
40 |
|
10 |
|
ANNUAL SUPPLY |
|
6 MONTH SUPPLY |
|
2 boxes (12 Lenses per Box) |
|
2 boxes (6 Lenses per Box) |
|
4 boxes (6 Lenses per Box) |
|
|
|
|
|
|
|
|
|
For questions or comments, please contact us at 18889986290.
TERMS & CONDITIONS. Purchases of ACUVUE OASYS® Family, 1Day ACUVUE® MOIST Family, 1Day ACUVUE® TruEye®, ACUVUE® VITA® and 1Day ACUVUE® DEFINE® must be made in-oice or in-store between April 1, 2017 and June 30, 2017.* Reward (rebate) requests with valid Reward Code obtained from place of purchase must be received within 60 days of purchase.** Product purchase must be made within 90 days after contact lens it/exam. Requires submission of product purchase receipt showing (a) patient name, (b) doctor irst/last name, (c) ACUVUE brand purchased, (d) number of boxes/lenses purchased, (e) date of purchase. Limit one reward per customer, per oer, per yearly eye exam visit. Limit four (4) reward requests per household per year. This oer is not valid in combination with any other product oer including Money Back Guarantee. Oer valid for U.S. residents only. Oer not valid where prohibited by law. Allow 14 days for delivery for electronic submissions, 68 weeks for alternative mail-in requests. No P.O. boxes, only street or rural addresses are acceptable for mail-in requests. Fraudulent submissions could result in federal prosecution under the U.S. Mail Fraud Statutes (18 U.S. Code Section 1341 and 1342). Not responsible for lost, late or undelivered responses.
ACUVUE® Rewards are only valid on invoice purchases and purchases made at select retail locations. Rewards are not valid for internet purchases and purchases made at large retailers including (but not limited to) Costco® Optical, Sam’s Club® Optical, BJ’s® Optical, Walmart® Optical or Target® Optical, but other oers may be available for ACUVUE® Brand purchases at these retailers.
NOTICE TO CONSUMERS: If you are personally iling a claim for reimbursement from a third-party payer (e.g., insurance company, employer group, etc.) for the purchase of this product, your claim must be based upon your payment less the amount of the rebate amount. If your doctor is iling the claim, you must notify the doctor’s oice of the need to deduct this rebate amount from the purchase price used in calculating the claim.
*Rewards are in the form of an ACUVUE® Brand Visa Prepaid card. Card is issued by the Bancorp Bank, Member FDIC, pursuant to a license from Visa U.S.A. Inc. **Johnson & Johnson Vision Care, Inc., reserves the right to cancel this rewards program and institute fraud prevention measures at any time without notice. Quantity requirements are based on typical purchase of lenses for two eyes.
ACUVUE®, ACUVUE® OASYS®, 1DAY ACUVUE® MOIST®, 1DAY ACUVUE® TruEye®, ACUVUE® VITA®, 1DAY ACUVUE® DEFINE® are trademarks of Johnson & Johnson Vision Care, Inc. ©Johnson & Johnson Vision Care, Inc., 2017.
The third-party trademarks used herein are trademarks of their respective owners.