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. 

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 (or a signed itemized receipt from provider has been attached). 

4. 	Please note that the member�s (or employee�s) signature is required on this form. 

5. 	Mail completed form along with original receipts to: 
	Vision Care Processing Unit, 
	P.O. Box 1525, 
	Latham, NY 12110. 

6. 	If you and your spouse are both members, you may be covered both as a member and as a dependent of a member. 			Similarly, your dependents may or may not be covered by both members. Please verify your coverage with your benefit 		office or call 1-800-999-5431. 

7. 	FOR PATIENTS RESIDING IN TN ONLY: 
	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. 


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 benefit provisions. Additionally, I have read and understand item 7, under Important Information, above. 


Member/Employee or authorized person�s signature 


Date