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Direct Reimbursement Claim Form Important Information

Summary: 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
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.
Member Name: _____________________________________________________________ Member Identification No.*:______________________
First Middle Initial Last
Mailing Address: _____________________________________________________________________________________________________________
Street City State Zip
Business Phone: ________________________________________________ Home Phone: _______________________________________________


Source: Awtar, Shorya - Department of Mechanical Engineering, University of Michigan
Whittle, Mark - Department of Astronomy, University of Virginia


Collections: Engineering; Physics