Vision Services Claim Form 2012 printable pdf download
Davis Vision Claim Form. Letter of authorization from client / group; You must include either your eye care professional’s signature or a detailed receipt.
Use this form to request reimbursement for services received from providers who do not participate in the davis vision network. Use this form to request reimbursement for services received from providers not in the davis vision network. Davis vision is a separate company that performs claims administration for your vision program. Use this form to request reimbursement for services received from providers who do not participate in the davis vision network. Box 791 latham, ny 12110 fax: To request reimbursement, complete and print this form, enclose a legible copy of your itemized receipt(s), and send them to the following address. Expenses for both examinations and eyewear can be claimed on this form. If a corrected claim has been attached, please specify revisions that were made: Expenses for both examinations and eyewear can be claimed on this form. Be sure to keep a copy for your records.
(choose one) ☐member ☐spouse ☐domestic partner. Only services listed on this form will be considered for reimbursement. Letter of authorization from client / group; You must include either your eye care professional’s signature or a detailed receipt. This change aligns davis vision and superior vision with cms guidelines on paper claims submission. Each patient’s services must be claimed on a separate form. Client / group name the request is regarding; Web direct reimbursement claim form important information: To request reimbursement, complete and print this form, enclose a legible copy of your itemized receipt(s), and send them to the following address. Only services listed on this form will be considered for reimbursement. Web log in to your account and click on “access benefits and forms” to download the direct reimbursement claim form.
