Get Direct Reimbursement Claim Form - Davis Vision

The Direct Reimbursement Claim Form - Davis Vision is designed to help users request reimbursement for vision services received from non-network providers. This guide will provide clear, step-by-step instructions to assist users in accurately completing the form online.

Follow the steps to accurately fill out the claim form.

1. Press the ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by filling in your member information. Clearly print your first name, middle initial, and last name, along with your member identification number. Provide your complete mailing address, including street, city, state, and zip code. Additionally, include your business and home phone numbers.
3. Next, provide the patient information, including the patient's name and relationship to the member. Enter the patient's date of birth to help ensure accurate processing.
4. Fill in the provider information for both the examiner and the dispenser, including their names, addresses, state license numbers, and phone numbers. It is important to ensure all details are accurate for the claim to be processed efficiently.
5. Detail the services incurred by entering the types of services received along with their respective dates of service and expenses incurred. Make sure to handle each item listed, and tally up the total expenses at the end.
6. As the member or authorized person, sign the claim form in the designated area to certify the information is correct and that you authorize the provider to release necessary information to process your claim.
7. After completing the form, ensure all sections are filled out completely. Save any changes, and choose to download, print, or share the completed form as required.

Start completing your Direct Reimbursement Claim Form - Davis Vision online for a hassle-free reimbursement experience.