Get Davis Vision Claim Form

Filling out the Davis Vision Claim Form online is a straightforward process that can help you request reimbursement for vision services. This guide will walk you through each step of completing the form accurately to ensure a smooth submission.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to download the claim form and open it in your preferred editor.
2. Begin by filling out the member/employee information section. Clearly print your name, member identification number, and mailing address. Make sure to include your business and home phone numbers.
3. Next, provide the patient information. Enter the patient's name, relationship to the member (select from member, spouse, or child), and date of birth. If the patient is a student aged 19 or over, attach written proof of attendance, if required.
4. Proceed to the provider information section. Fill in the names and addresses of the examiner and dispenser, along with their state license numbers and phone numbers. Ensure all details are correct.
5. In the service section, record each service provided. Indicate the date of service, then provide the amount for each type of service (e.g., eye examination, lenses, frames, etc.) to summarize total costs.
6. Complete the member/employee certification section. Confirm that all information is accurate, and authorize the provider to release pertinent information for claim processing. Remember to sign and date the form here.
7. Once every section is thoroughly filled out, review the form for any missing information or errors. Save your changes before proceeding.
8. Finally, after confirming the form is complete and accurate, you can download, print, or share the claim form for submission. Ensure to mail it to the provided address.

Start completing your Davis Vision Claim Form online today for a more streamlined reimbursement process!