Fillable Printable Direct Reimbursement Calim Form - University of Virginia
Fillable Printable Direct Reimbursement Calim Form - University of Virginia
Direct Reimbursement Calim Form - University of Virginia
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 foreligible 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, NY12110.
7. The completion and submission of this form does not guarantee eligibility for benefits. Please verify your coverage with your benefits office
or call 1-800-999-5431 or visit www.davisvision.com. The patient is responsible for the costs of all treatment and materials provided.
Member/Employee Information
* Your Member Identification No. is the number by which the company that sponsors your vision care benefits identifies you.
(PLEASE PRINTCLEARLY)
Member Name:_____________________________________________________________Member Identification No.*:______________________
FirstMiddle InitialLast
Mailing Address:_____________________________________________________________________________________________________________
StreetCityStateZip
Business Phone:________________________________________________Home Phone:_______________________________________________
Area CodeArea Code
Patient Information
Patient Name:________________________________________________________
FirstMiddle InitialLast
Relationship:MemberSpouseChild DOB:______________If student aged 19 or over, attach written proof of attendance at school (if required)
Are you and your spouses benefits both provided by the same agency?YesNo
Member/Employee Certification
I certify that the information on this form is correct and authorize the Provider to release appropriate information necessary to process this claim to plan provisions. Additionally,
Ihave read and understand the fraud statement on the back of this form.
_____________________________________________________________ ___________________
Member/Employee orauthorized person’s signatureDate
Provider Information
ExaminerDispenser
Name:________________________________________________________Name:________________________________________________________
Address:_______________________________________________________Address:______________________________________________________
City:__________________________State:____Zip:________________City:__________________________State:____Zip:______________
State License Number:___________________________________________State License Number:__________________________________________
Phone Number:__________________________________________________Phone Number:________________________________________________
ProviderSignature:_____________________________________________ProviderSignature:____________________________________________
ServiceDate of ServiceAmount
1. Eye Examination( / / )$
2. Frames( / / )$
3. Single Vision Lenses ( / / )$
4. Bifocal Lenses( / / )$
5. Trifocal Lenses( / / )$
6. Contact Lenses( / / )$
7. Cataract S.V. Lenses( / / )$
8. Cataract Bifocal Lenses( / / )$
9. Medically Necessary Contact Lenses( / / )$
Total$
SC00015 9/21/04
FOR INTERNALUSE ONLY
Auth #:________________________________
Paid Denied Pended
Required
FRAUD STATEMENT
Any person who knowingly and with intent to defraud and deceive any insurance company submits
an insurance application or statement of claim containing any false, incomplete or misleading
information may be subject to civil or criminal penalties, depending upon state law.
In Florida, any person who knowingly and with intent to injure, defraud or deceive any insurer files
a statement of claim or an insurance application containing any false, incomplete or misleading
information is guilty of a felony of the third degree.
In New Jersey, any person who includes any false or misleading information on an application for
insurance is subject to criminal and civil penalties.
In New York, applicants for Accident and Health Insurance: 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 shall also be subject to a civil penalty not to exceed five thousand dollars and
the stated value of the claim for each such violation.
In Kentuckyand Pennsylvania, 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 person to
criminal and civil penalties.
In Tennessee,state law stipulates that it is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the purpose of defrauding the company. Penalties
include imprisonment, fines and denial of insurance benefits.
SC00015 9/21/04
