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Received by Davis Vision PRIOR APPROVAL REQUEST FORM Submit To Toll Free Fax 1-800-584-2329 Important PLEASE VERIFY MEMBER BENEFIT PRIOR TO SUBMITTING REQUEST. Patient Information Patient Name Patient DOB Member ID Number New Patient Yes No Member Name Group Employer Name Date of Service Provider Information Provider Name Please Print Provider Email Address Provider Panel Number Required Date of Request Provider Telephone Number Provider Fax Number Please Mark Services Requested Exam Only Eyeglasses only Low Vision Evaluation Exam Eyeglasses Repair/Replace Reason Contact Lens Evaluation Is there a medical condition related to this request Additional Exam Keratoconus Progressive Myopia Anisometropia Aphakia Pathological Myopia Post Cataract Date Last Surgery Diabetes Other Provider Comments Supporting Documents Attached Prescription Information Required Rx Glasses Contact Lenses OD VA OD / OS VA OS / Professional Fee Material Fee Low Vision Aids Both Old and New Prescription Must Be Com....

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Related content

2020 Davis Vision Member Handbook - TN.gov
Davis Vision Exclusive Collection based upon plan design. davisvision.com/stateofTN | 2...
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Direct Reimbursement Claim Form
... received from providers who do not participate in the Davis Vision network. ... No. is...
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2019 provider manual - UserManual.wiki
Contact Davis Vision at 1-800-999-5431 ... coverage of a number of vaccines, some of which...
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Davis Vision and Superior Vision are part of the MetLife family of companies.

Davis Vision Plan provides access to care through private practice providers and national retailers, including: Visionworks, , Sam's Club, Walmart, For Eyes, and more.

Originating as a family retail optical business established in 1917, modern day Davis Vision was incorporated in 1964 when founder Lawrence Davis opened a small ophthalmic laboratory in New Hyde Park, New York.

Versant Health, Inc., a wholly-owned subsidiary of MetLife, Inc., is one of the nation's leading administrators of managed vision care, serving more than 38.5 million of our clients' members nationwide.

CPT 92002, 92004, 92012, 92014, 92015, S0620, and S0621 are reported per patient and not per eye. These procedures are considered to be unilateral or bilateral and may only be reimbursed once per encounter.

Jim Eisen serves as the CEO / President of Davis Vision. Tim Carney serves as the Senior Vice President of Sales and Marketing of Davis Vision.

Versant Health owns the well-established marketplace brands Davis Vision and Superior Vision.

WHAT IS THE DAVIS VISION CONTACT LENS COLLECTION? As with eyeglass frames, Davis Vision offers a special Collection of contact lenses to members, which greatly minimizes out-of-pocket costs. The Collection is available only at independent network providers that also carry the Davis Vision Collection frames.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232