Get Davis Vision Direct Reimbursement Claim Form 2017-2025
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Davis Vision Direct Reimbursement Claim Form online
The Davis Vision Direct Reimbursement Claim Form is a vital document for requesting reimbursement for vision services received from non-network providers. This guide will provide clear, step-by-step instructions for completing the form online, ensuring a smooth submission process.
Follow the steps to complete the Davis Vision Direct Reimbursement Claim Form online
- Press the ‘Get Form’ button to access the Davis Vision Direct Reimbursement Claim Form and open it in your online document editor.
- Begin by filling out the member/employee information section. Clearly print your first name, middle initial, and last name, followed by your member identification number. Also, provide your complete mailing address, including street, city, state, and zip code.
- Input your business phone and home phone number in the designated fields, ensuring you include the appropriate area codes.
- Proceed to the patient information section. Enter the patient’s name, date of birth, and their relationship to the member, selecting from member, spouse, or child. If applicable, attach proof of school attendance for students aged 19 or over.
- In the provider information section, provide the names and addresses of both the examiner and dispenser. Make sure to include city, state, and zip code, along with their state license numbers and phone numbers.
- Complete the service section by entering the date of service and incurred expenses for each item, such as eye examination, frames, and various types of lenses. Ensure all entries are accurate and totaled.
- In the member/employee certification section, sign and date the form to confirm that all information provided is correct and that you authorize the release of necessary information.
- Review the entire form to ensure all sections are completed. Once satisfied, save any changes made in the editor. You can also download, print, or share the form as needed for submission.
Complete your Davis Vision Direct Reimbursement Claim Form online today for a straightforward reimbursement process.
Processing a reimbursement claim involves filling out the Davis Vision Direct Reimbursement Claim Form and providing all required documentation. After preparing your claim, send it to your insurance provider via their preferred method, usually online or by mail. Ensure you keep copies of all materials for your records until you receive reimbursement confirmation.
Industry-leading security and compliance
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.