Vision Reimbursement Form printable pdf download

FOR INTERNAL USE ONLY

Auth #: ________________________________

Paid

Denied

Pended

Direct Reimbursement Claim Form

Important Information:

1. Use this form to request reimbursement for services received from providers who do not participate in the Davis Vision network.

2. Expenses for both examinations and eyewear can be claimed on this form. Only services listed on this form will be considered for

reimbursement.

3. Make sure that all sections are completed, that you and the providers(s) have signed the form, and that all services, charges, and

service dates have been entered. If the form is incomplete, additional information may be required. This may result in a delay of

payment for eligible benefits.

4. Please submit claim reimbursement for each patient on a separate claim form.

5. Please note that the member’s (or employee’s or authorized person’s) signature is required on this form.

6. Mail completed claim form to: Vision Care Processing Unit, P.O. Box 1525, Latham, NY 12110.

7. The completion and submission of this form does not guarantee eligibility for benefits. Please verify your coverage with your benefits office

or call 1-888-393-2583 or visit The patient is responsible for the costs of all treatment and materials provided.

Member/Employee Information

(PLEASE PRINT CLEARLY)

Member Name: _____________________________________________________________

Member Identification No.:_______________________

First

Middle Initial

Last

Mailing Address: _____________________________________________________________________________________________________________

State

Zip

Street

City

Business Phone: ________________________________________________

Home Phone: _______________________________________________

Area Code

Patient Information

Patient Name:

________________________________________________________

First

Middle Initial

Last

Relationship:

Member

Spouse

Child DOB: ______________

Provider Information

Examiner

Dispenser

Name: ________________________________________________________

Name:________________________________________________________

Address: _______________________________________________________

Address: ______________________________________________________

City: __________________________ State: ____ Zip: ________________

City: __________________________ State: ____ Zip: ______________

State License Number: ___________________________________________

State License Number: __________________________________________

Phone Number:__________________________________________________

Phone Number: ________________________________________________

Provider Signature: _____________________________________________

Provider Signature: ____________________________________________

Service

Date of Service

Amount

1. Eye Examination

(

)

2. Frames

(

)

3. Single Vision Lenses

Polycarbonate

(

)

4. Bifocal Lenses

Progressive

Polycarbonate

(

)

5. Trifocal Lenses

Polycarbonate

(

)

6. Contact Lenses

Conventional

Disposable

(

)

7. Cataract S.V. Lenses*

Polycarbonate

(

)

8. Cataract Bifocal Lenses*

Progressive

Polycarbonate

(

)

9. Medically Necessary Contact Lenses*

(

)

Total

(*) These services are not applicable for Keystone 65, Personal Choice 65, Security 65 or 65 Special members.

Please refer to your medical coverage for these benefits.

Member Certification

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially

false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects

such a person to criminal and civil penalties. PROVIDERS: By signing this document, you swear or affirm that the services or materials for which this claim is being made were

necessary and were, in fact, furnished.

For Keystone Health Plan East Participants:

For participants in ERISA self-funded products, references to subscriber/member shall include participants, and payments for covered services will be made by Keystone Health

Plan East on behalf of the employer group.

I certify that the information on this form is correct and authorize the Provider to release the appropriate information necessary to process this claim to plan benefit provisions.

Required

_____________________________________________________________

________________

Member’s or authorized person’s signature

Date

MS00209

1/5/07