Davis Vision Claim Form

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Davis Vision Claim Form. Web davis vision by metlife member reimbursement form. If a corrected claim has been attached, please specify revisions that were made:

Expenses for both examinations and eyewear can be claimed on this form. This change aligns davis vision and superior vision with cms guidelines on paper claims submission. Only services listed on this form will be considered for reimbursement. Expenses for both examinations and eyewear can be claimed on this form. Davis vision is a separate company that performs claims administration for your vision program. To request reimbursement, complete and print this form, enclose a legible copy of your itemized receipt(s), and send them to the following address. Letter of authorization from client / group; Use this form to request reimbursement for services received from providers not in the davis vision network. Box 791 latham, ny 12110 fax: Please submit to the following contact:

Davis vision complaints and appeals department p.o. Only services listed on this form will be considered for reimbursement. Web vendor maintenance request form (excel) additionally, ensure you include the following: Web davis vision has been providing comprehensive vision care benefits for over 50 years. Web log in to your account and click on “access benefits and forms” to download the direct reimbursement claim form. Davis vision is a separate company that performs claims administration for your vision program. Each patient’s services must be claimed on a separate form. Letter of authorization from client / group; Expenses for both examinations and eyewear can be claimed on this form. Expenses for both examinations and eyewear can be claimed on this form. Client / group name the request is regarding;