Davis Vision Out Of Network Form. All fields flagged with an asterisk (*) are required. Web form instructions the form must be filled out by the member.
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Web use this form to request reimbursement for services received from providers who do not participate in the davis vision network. Available in all ranges of prescriptions and sizes with tinting and scratch resistant coating frame12 months Expenses for both examinations and eyewear can be claimed on this form. Includes dilation when professionally indicated. Expenses for both examinations and eyewear can be listed on this form. Web use this form to request reimbursement for services received from providers who do not participate in the davis vision network. Only one patient’s services may 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. Web vision service plan (vsp) attn: If you decide to hand write, use blue or black ink.
Box 1525 latham, ny 12110 united healthcare vision (spectera) attn: Fill it out on a computer, print it, and mail it in. All fields flagged with an asterisk (*) are required. Web form instructions the form must be filled out by the member. Web use this form to request reimbursement for services received from providers who do not participate in the davis vision network. Select the patient’s relation to the member. Vision care processing unit p.o. Attach an itemized receipt to the form. Includes dilation when professionally indicated. Only one patient’s services may be claimed on this form. Web vision service plan (vsp) attn:
