Loading...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