Get Direct Reimbursement Claim Form - Ibx

The Direct Reimbursement Claim Form - IBX is designed for individuals seeking reimbursement for services received from providers outside the Davis Vision network. This guide will provide clear instructions on how to accurately complete the form online, ensuring a smooth and efficient reimbursement process.

Follow the steps to complete your Direct Reimbursement Claim Form - IBX online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal information in the Member/Employee Information section. This includes your full name, member identification number, mailing address, and phone numbers. Ensure all details are correct for processing.
3. In the Patient Information section, provide the patient's full name and relationship to you. You are required to include the date of birth of the patient.
4. Fill out the Provider Information section by entering the name, address, contact number, and state license number of both the examiner and dispenser. Each provider must sign in the designated area.
5. In the Service section, list the applicable services, including eye exams, frames, lenses, and any necessary additional services with their respective dates of service. Be sure to select any applicable options for lenses by marking ‘yes’ or ‘no’ where required.
6. Document the total expenses incurred for all services rendered in the Expense(s) Incurred section. Clearly reflect each amount and ensure that the total is accurate.
7. Sign the Member Certification section to attest that all information is correct. This signature must be dated as well. Note that an authorized person may sign if applicable.
8. Review the completed form meticulously to ensure no fields are left empty. After confirming that all required information is provided, proceed to save your changes, download, print, or share the completed form as needed.

Complete your Direct Reimbursement Claim Form - IBX online to ensure timely reimbursement for your services.