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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How to fill out the Davis Vision Fax Number online
Filling out the Davis Vision Fax Number form online can be an efficient way to submit your request for services. This guide will help you navigate each section of the form, ensuring that you provide all necessary information accurately.
Follow the steps to complete the form smoothly.
- Click ‘Get Form’ button to access the form and open it in the editor.
- Begin by entering the patient information. Fill in the patient's name and date of birth, along with the member ID number. Indicate if this is a new patient by selecting 'Yes' or 'No'.
- Provide the member's name, group employer name, and date of service. This information is essential for processing the request accurately.
- In the provider information section, fill in the provider's name (please print), email address, panel number, date of request, telephone number, and fax number.
- Next, specify the services requested by marking the appropriate options such as 'Exam Only', 'Eyeglasses only', or 'Exam & Eyeglasses'. If applicable, describe the reason for the request in the provided space.
- Indicate whether there is a medical condition related to this request by selecting 'Yes' or 'No'. If 'Yes', select from the provided conditions or specify another condition.
- Complete the sections for prescription information required, including details for both old and new prescriptions for eyeglasses and contact lenses. Ensure that you complete the 'Professional Fee' and 'Material Fee' sections as well.
- Finally, review all the entries for accuracy. At the end of the form, either save changes, download, print, or share the completed form as required.
Complete and submit your Davis Vision Fax Number form online today for efficient processing.
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Get answers to your most pressing questions about US Legal Forms API.
Is Davis vision and MetLife the same?
Davis Vision and Superior Vision are part of the MetLife family of companies.
Can I use Davis Vision at ?
Davis Vision Plan provides access to care through private practice providers and national retailers, including: Visionworks, , Sam's Club, Walmart, For Eyes, and more.
Who started Davis vision?
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.
Who owns Versant Health?
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.
What are the procedure codes for Davis Vision?
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.
Who is the CEO of Davis vision?
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.
Who owns Davis Vision?
Versant Health owns the well-established marketplace brands Davis Vision and Superior Vision.
What are Davis Vision Collection contacts?
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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