Direct Reimbursement Claim Form
Important Information:
1. Use this form to request reimbursement for services received from providers who do not participate in the Davis Vision network.
2. Expenses for both examinations and eyewear can be claimed on this form. Only services listed on this form will be considered for
reimbursement.
3. Make sure that all sections are completed, that you and the providers(s) have signed the form, and that all services, charges, and
service dates have been entered. If the form is incomplete, additional information may be required. This may result in a delay of
payment for eligible benefits.
4. Please submit claim reimbursement for each patient on a separate claim form.
5. Please note that the member’s (or employee’s or authorized person’s) signature is required on this form.
6. Mail completed claim form to: Vision Care Processing Unit, P.O. Box 1525, Latham, NY 12110.
7. The completion and submission of this form does not guarantee eligibility for benefits. Please verify your coverage with your benefits office
or call 1-800-999-5431 or visit www.davisvision.com. The patient is responsible for the costs of all treatment and materials provided.
Member/Employee Information
* Your Member Identification No. is the number by which the company that sponsors your vision care benefits identifies you.
(PLEASE PRINT CLEARLY)
Member Name: _____________________________________________________________ Member Identification No.*:______________________
First Middle Initial Last
Mailing Address: _____________________________________________________________________________________________________________
Street City State Zip
Business Phone: ________________________________________________ Home Phone: _______________________________________________
Area Code Area Code
Patient Information
Patient Name: ________________________________________________________
First Middle Initial Last
Relationship: Member Spouse Child DOB: ______________ If student aged 19 or over, attach written proof of attendance at school (if required)
Are you and your spouse’s benefits both provided by the same agency? Ye s No
Member/Employee Certification
I certify that the information on this form is correct and authorize the Provider to release appropriate information necessary to process this claim to plan provisions. Additionally,
I have read and understand the fraud statement on the back of this form.
_____________________________________________________________ ___________________
Member/Employee or authorized person’s signature Date
Provider Information
Examiner Dispenser
Name: ________________________________________________________ Name:________________________________________________________
Address: _______________________________________________________ Address: ______________________________________________________
City: __________________________ State: ____ Zip: ________________ City: __________________________ State: ____ Zip: ______________
State License Number: ___________________________________________ State License Number: __________________________________________
Phone Number:__________________________________________________ Phone Number: ________________________________________________
Provider Signature: _____________________________________________ Provider Signature: ____________________________________________
Service Date of Service Expense(s) Incurred
1. Eye Examination ( / / ) $
2. Frames ( / / ) $
3. Single Vision Lenses ( / / ) $
4. Bifocal Lenses ( / / ) $
5. Trifocal Lenses ( / / ) $
6. Contact Lenses ( / / ) $
7. Cataract S.V. Lenses ( / / ) $
8. Cataract Bifocal Lenses ( / / ) $
9. Medically Necessary Contact Lenses ( / / ) $
Total $
SC00015 11/15/12
FOR INTERNAL USE ONLY
Auth #: ________________________________
Paid Denied Pended
Required
