Davis Vision Out Of Network Form. All fields flagged with an asterisk (*) are required. Web use this form to request reimbursement for services received from providers who do not participate in the davis vision network.
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Box 30978 salt lake city, ut 84130 fill in and sign the following form. Each patient’s services must be claimed on a separate form. All fields flagged with an asterisk (*) are required. If you decide to hand write, use blue or black ink. Box 1525 latham, ny 12110 united healthcare vision (spectera) attn: Includes dilation when professionally indicated. Select the patient’s relation to the member. Web 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. Web 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. Select the patient’s relation to the member. Web vision service plan (vsp) attn: Attach an itemized receipt to the form. Only one patient’s services may be claimed on this form. Includes dilation when professionally indicated. Each patient’s services must be claimed on a separate form. Web form instructions the form must be filled out by the member. If you decide to hand write, use blue or black ink. Vision care processing unit p.o. Box 1525 latham, ny 12110 united healthcare vision (spectera) attn:
