Get Direct Reimbursement Claim Form Important ... - Davis Vision

This guide provides a step-by-step approach to completing the Direct Reimbursement Claim Form Important ... - Davis Vision online. By following these instructions, you can ensure that your reimbursement request is submitted accurately and efficiently.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to retrieve the form and open it for editing.
2. Begin filling out the enrollee/employee information section. Make sure to clearly write your name, including your first, middle initial, and last name. Provide your enrollee identification number and a complete mailing address, including the street, city, state, and zip code.
3. Enter your business and home phone numbers in the specified sections, including the area codes.
4. Move on to the patient information section. Input the patient's full name, and indicate their relationship to you by checking the appropriate box for member, spouse, or child. Include the patient's date of birth.
5. Answer whether the patient has other vision coverage by checking 'Yes' or 'No' in the provided section.
6. Complete the provider information section by entering the names and addresses of both the examiner and dispenser. Include the state license numbers and phone numbers of each provider.
7. In the services section, list each service received, along with the corresponding date of service and incurred expenses. Ensure all relevant fields are filled out for eye examinations, frames, lenses, and any applicable services.
8. In the enrollee/employee certification section, sign and date the form, certifying that the information is accurate and authorizing the provider to release necessary details for claim processing.
9. Review the entire form for completeness. Ensure both your signature and the provider’s signature are present, especially if a detailed receipt is not attached.
10. Once all sections are completed, save changes to the document, and then download, print, or share the completed form as needed.

Complete your Direct Reimbursement Claim Form online today to ensure timely reimbursement.