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 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 1-800-999-5431 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 PRINT CLEARLY)

Member Name: _____________________________________________________________ Member Identification No.*:______________________

First Middle Initial Last

Mailing Address: _____________________________________________________________________________________________________________

Street City State Zip

Business Phone: ________________________________________________ Home Phone: _______________________________________________

Area Code Area Code

Patient Information

Patient Name: ________________________________________________________

First Middle Initial Last

Relationship:  Member  Spouse  Child 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?  Yes  No

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,

I have read and understand the fraud statement on the back of this form.

_____________________________________________________________ ___________________

Member/Employee or authorized person’s signature Date

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 ( / / ) $

4. Bifocal Lenses ( / / ) $

5. Trifocal Lenses ( / / ) $

6. Contact Lenses ( / / ) $

7. Cataract S.V. Lenses ( / / ) $

8. Cataract Bifocal Lenses ( / / ) $

9. Medically Necessary Contact Lenses ( / / ) $

Total $

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FOR INTERNAL USE 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 Kentucky and 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.

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