Davis Vision Out Of Network Form. Only one patient’s services may be claimed on this form. Use this form to request reimbursement for services received from providers not in the davis vision network.
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Web use this form to request reimbursement for services received from providers who do not participate in the davis vision network. Vision care processing unit p.o. Box 1525 latham, ny 12110 united healthcare vision (spectera) attn: All fields flagged with an asterisk (*) are required. Log in to your account and click on “access benefits and forms” to download the direct reimbursement claim form. Expenses for both examinations and eyewear can 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. Web use this form to request reimbursement for services received from providers who do not participate in the davis vision network. Each patient’s services must be claimed on a separate form. Expenses for both examinations and eyewear can be claimed on this form.
Box 1525 latham, ny 12110 united healthcare vision (spectera) attn: Expenses for both examinations and eyewear can be claimed on this form. Includes dilation when professionally indicated. Vision care processing unit p.o. Box 1525 latham, ny 12110 united healthcare vision (spectera) attn: Each patient’s services must be claimed on a separate form. Attach an itemized receipt to the form. Only one patient’s services may be claimed on this form. The form is fillable, so you do not have to hand write. Web vision service plan (vsp) attn: Fill it out on a computer, print it, and mail it in.
