Davis Vision Out Of Network Claim Form. Use this form to request reimbursement for services received from providers not in the davis vision network. Box 30978 salt lake city, ut 84130 fill in and sign the following form.
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Use this form to request reimbursement for services received from providers not in the davis vision network. They are licensed providers in both private practice and retail locations who are extensively reviewed and credentialed to ensure that stringent standards for quality service are maintained. Enter the date of service in the following format: Each patient’s services must be claimed on a separate form. Mail the signed, completed form and itemized receipt to your vision insurance company. Box 1525 latham, ny 12110 united healthcare vision (spectera) attn: Enter the amount charged for each applicable line item. Web use this form to request reimbursement for services received from providers who do not participate in the davis vision network. The provider’s office will verify your eligibility for services, and no claim forms are required. Web davis vision has been providing comprehensive vision care benefits for over 50 years.
Who are the network providers? Enter the date of service in the following format: Only one patient’s services may be claimed on this form. Expenses for both examinations and eyewear can be claimed on this form. Each patient’s services must be claimed on a separate form. The provider’s office will verify your eligibility for services, and no claim forms are required. Attach an itemized receipt to the form. Do members need a claim form for services? Expenses for both examinations and eyewear can be listed on this form. If another insurance company is involved, check the box and attach a copy of the statement showing payment. Expenses for both examinations and eyewear can be claimed on this form.
