Direct Reimbursement Claim Form
Davis Vision Out Of Network Claim Form. Box 1525 latham, ny 12110 united healthcare vision (spectera) attn: Ensure they match the receipts.
The provider’s office will verify your eligibility for services, and no claim forms are required. Expenses for both examinations and eyewear can be claimed on this form. Log in to your account and click on “access benefits and forms” to download the direct reimbursement claim form. Mail the signed, completed form and itemized receipt to your vision insurance company. Web use this form to request reimbursement for services received from providers who do not participate in the davis vision network. Vision care processing unit p.o. Who are the network providers? Box 30978 salt lake city, ut 84130 fill in and sign the following form. Attach an itemized receipt to the form. Ensure they match the receipts.
Enter the date of service in the following format: Enter the date of service in the following format: Vision care processing unit p.o. Who are the network providers? Web use this form to request reimbursement for services received from providers who do not participate in the davis vision network. Do members need a claim form for services? Box 30978 salt lake city, ut 84130 fill in and sign the following form. Attach an itemized receipt to the form. If another insurance company is involved, check the box and attach a copy of the statement showing payment. Only one patient’s services may be claimed on this form. Expenses for both examinations and eyewear can be claimed on this form.
