Always Care Vision Claim Form 20202021 Fill and Sign Printable
Davis Vision Claim Form. To request reimbursement, complete and print this form, enclose a legible copy of your itemized receipt(s), and send them to the following address. Expenses for both examinations and eyewear can be claimed on this form.
Always Care Vision Claim Form 20202021 Fill and Sign Printable
Only services listed on this form will be considered for reimbursement. Web davis vision by metlife member reimbursement form. Box 791 latham, ny 12110 fax: Use this form to request reimbursement for services received from providers not in the davis vision network. Web direct reimbursement claim form important information: Be sure that all sections have been completed and that you and the provider(s) have. Use this form to request reimbursement for services received from providers who do not participate in the davis vision network. Letter of authorization from client / group; Follow the instructions on the form to submit your claim. Please submit to the following contact:
Web direct reimbursement claim form important information: Web direct reimbursement claim form important information: Expenses for both examinations and eyewear can be claimed on this form. Please submit to the following contact: If a corrected claim has been attached, please specify revisions that were made: You must include either your eye care professional’s signature or a detailed receipt. Davis vision is a separate company that performs claims administration for your vision program. Box 791 latham, ny 12110 fax: Only services listed on this form will be considered for reimbursement. Client / group name the request is regarding; Each patient’s services must be claimed on a separate form.
