Davis Vision Out Of Network Claim Form. Only one patient’s services may be claimed on this form. Attach an itemized receipt to the form.
Direct Reimbursement Claim Form
Attach an itemized receipt to the form. Ensure they match the receipts. Box 30978 salt lake city, ut 84130 fill in and sign the following form. Mail the signed, completed form and itemized receipt to your vision insurance company. Each patient’s services must be claimed on a separate form. Vision care processing unit p.o. If another insurance company is involved, check the box and attach a copy of the statement showing payment. Use this form to request reimbursement for services received from providers not in the davis vision network. Enter the date of service in the following format: Only one patient’s services may be claimed on this form.
Web use this form to request reimbursement for services received from providers who do not participate in the davis vision network. Expenses for both examinations and eyewear can be claimed on this form. Who are the network providers? The provider’s office will verify your eligibility for services, and no claim forms are required. Expenses for both examinations and eyewear can be claimed on this form. Each patient’s services must be claimed on a separate form. Web use this form to request reimbursement for services received from providers who do not participate in the davis vision network. Box 1525 latham, ny 12110 united healthcare vision (spectera) attn: Use this form to request reimbursement for services received from providers not in the davis vision network. Enter the date of service in the following format: If another insurance company is involved, check the box and attach a copy of the statement showing payment.
