vision_reimbursement.pdf.png
96 Downloads
0 0

Download the Davis Vision Reimbursement Claim Form. PLEASE NOTE: If you are a member of the Davis Vision Group, you do not require a claim form of any kind. All that is needed is to provide your name. The rest is on file, it’s that easy. However, if you are not a member and have paid out of pocket for services or if you have used Davis Vision Services as an out-of-network provider and you are entitled to reimbursement, complete the form provided.

How To Write

Step 1 – Read all information at the top of this reimbursement form. Each claim will require a separate claim form.

Step 2 – Section 1 – Member/Employee Information –

  • Member Name – First, Middle, Last
  • Member Identification Number
  • Mailing Address – Street, City State, Zip
  • Business Phone (with area code)
  • Home Phone (with area code)

Step 2 – Section 2 – Patient Information

  • Patient Name – First, Middle, Last
  • Relationship (check the box that applies)

Step 3 – Section 3 – Provider Information

This information is to be completed by the vision service provider during your visit. They are to complete all of the information in section 3 and provide signature.

  • Please Note: These Services are not applicable for Keystone 65, Personal Choice 65, Security 65 or 65 Special Members. You will need to refer to your medical coverage for these benefits.

Step 4 – Section 4 – Member Certification –

  • Read this section in it’s entirety prior to providing signature
  • Once you have read, understand and agree:
  • Member’s or authorized person’s signature and date mm/dd/yyyy
  • As a precaution- read the fraud statement at the end of this form

Preview

Adobe PDF