Get Davis Vision Claim

Filing a Davis Vision Claim online is a straightforward process that allows users to request reimbursement for vision care services received from non-network providers. This guide provides a step-by-step approach to ensure that you complete the claim form accurately and efficiently.

Follow the steps to fill out the Davis Vision Claim successfully.

1. Press the ‘Get Form’ button to obtain the Davis Vision Claim form and open it in your preferred document editor.
2. In the Member/Employee Information section, fill in your full name, Member Identification Number, and, if necessary, your Social Security Number. Ensure that all details are clear and legible.
3. Provide your mailing address, including street, city, state, and zip code. Include both your business and home phone numbers.
4. In the Patient Information section, enter the patient’s name, relationship to you, and date of birth. For students aged 19 or over, remember to attach written proof of attendance if needed.
5. Indicate whether you and your spouse have benefits provided by the same agency by selecting 'Yes' or 'No'.
6. In the Provider Information section, list the names and addresses of both the examiner and the dispenser involved in the patient's care, along with their Federal Tax I.D. numbers and phone numbers.
7. In the Service section, detail each service provided, including the date of service and the amount charged for each item. Make sure to list all relevant services such as eye examinations, lenses, and frames.
8. Calculate the total reimbursement amount by summing all individual service charges.
9. Sign and date the Member/Employee Certification section to confirm the accuracy of the information provided. Make sure to read and understand the important information section before signing.
10. Once completed, save your changes, and prepare to download, print, or share the form along with original receipts to the designated address.

Complete your Davis Vision Claim online today and ensure you receive the reimbursement you deserve.