Vision Services Claim Form 2012 printable pdf download
Davis Vision Claim Form. Expenses for both examinations and eyewear can be claimed on this form. Box 791 latham, ny 12110 fax:
Vision Services Claim Form 2012 printable pdf download
Davis vision complaints and appeals department p.o. Box 791 latham, ny 12110 fax: Web direct reimbursement claim form important information: Web log in to your account and click on “access benefits and forms” to download the direct reimbursement claim form. Follow the instructions on the form to submit your claim. (choose one) ☐member ☐spouse ☐domestic partner. 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 not in the davis vision network. Use this form to request reimbursement for services received from providers who do not participate in the davis vision network. Web davis vision by metlife member reimbursement form.
Client / group name the request is regarding; Only services listed on this form will be considered for reimbursement. Web vendor maintenance request form (excel) additionally, ensure you include the following: Web log in to your account and click on “access benefits and forms” to download the direct reimbursement claim form. Follow the instructions on the form to submit your claim. 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. Each patient’s services must be claimed on a separate form. Please submit to the following contact: Be sure to keep a copy for your records. Only services listed on this form will be considered for reimbursement.
