File a claim with davis and vision 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Member/Employee Information section. Clearly print your name, identification number, and contact details including your mailing address and phone numbers.
3. Next, provide Patient Information. Indicate the patient's name, relationship to the member, date of birth, and if applicable, attach proof of school attendance for students aged 19 or over.
4. In the Provider Information section, enter the names and addresses of both the examiner and dispenser. Ensure you include their state license numbers and phone numbers.
5. List all services received in the Service section. For each service (e.g., eye examination, frames), input the date of service and corresponding expenses incurred.
6. Finally, complete the Member/Employee Certification by signing and dating the form to confirm that all information is accurate.

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