Get Doctisi

Filling out the Doctisi form online is a straightforward process that ensures your vision and flu shot claims are submitted accurately and efficiently. This guide will take you through each step required to complete the form effortlessly.

Follow the steps to complete your Doctisi form successfully.

1. Press the ‘Get Form’ button to access the form and open it in your chosen editor.
2. Begin by entering your identification number in Item #1. This number is essential for processing your claim and can be found on the front of your insurance ID card.
3. In Item #2, input your group number, which is required to associate your claim with your specific coverage plan.
4. Provide the patient’s name in Item #3 by writing the last name, first name, and middle initial clearly.
5. Fill in the patient’s birthdate in Item #4, noting the month, day, and year in the designated fields.
6. Indicate the patient’s sex in Item #5 by selecting either 'male' or 'female.'
7. In Item #6, specify the relationship between the patient and the subscriber, selecting from options such as self, spouse, or child.
8. Complete Item #7 by entering the subscriber’s name in a similar format to the patient’s name.
9. Fill out Item #8 with the subscriber's address, including street, city, state, and zip code.
10. Answer ‘yes’ or ‘no’ to the questions regarding coordination of benefits in Items #9 through #13, providing additional details where applicable.
11. In Item #14, describe the illness or symptoms that necessitated the reimbursement request.
12. Input the name of the provider or hospital facility in Item #15 where services were rendered.
13. If the service was provided at an outpatient hospital, detail this information in Item #16.
14. Fill out Items #19 through #23 with information regarding services received, including dates, places, and total charges.
15. Once all fields are completed, ensure to sign and date the form in Item #24 to certify the accuracy and completeness of the information.
16. After reviewing the form for completeness, save your changes, and then you can download, print, or share the form as needed.

Start your claims process today by completing the Doctisi form online.