Davis Vision "Out of Network" claim form by Drs. Stahl & Calder Issuu
Davis Vision Claim Form. Client / group name the request is regarding; Only services listed on this form will be considered for reimbursement.
(choose one) ☐member ☐spouse ☐domestic partner. Expenses for both examinations and eyewear can be claimed on this form. Web davis vision has been providing comprehensive vision care benefits for over 50 years. Expenses for both examinations and eyewear can be claimed on this form. Please submit to the following contact: Davis vision is a separate company that performs claims administration for your vision program. Only services listed on this form will be considered for reimbursement. Use this form to request reimbursement for services received from providers not in the davis vision network. Web vendor maintenance request form (excel) additionally, ensure you include the following: Client / group name the request is regarding;
Follow the instructions on the form to submit your claim. (choose one) ☐member ☐spouse ☐domestic partner. Web davis vision has been providing comprehensive vision care benefits for over 50 years. Be sure to keep a copy for your records. This change aligns davis vision and superior vision with cms guidelines on paper claims submission. Davis vision complaints and appeals department p.o. Only services listed on this form will be considered for reimbursement. To request reimbursement, complete and print this form, enclose a legible copy of your itemized receipt(s), and send them to the following address. Use this form to request reimbursement for services received from providers who do not participate in the davis vision network. Client / group name the request is regarding; Expenses for both examinations and eyewear can be claimed on this form.
