Davis vision claim fax number form 2026

1. Click ‘Get Form’ to open the davis vision claim fax number form 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. Enter the patient's name, relationship to you, and date of birth. If applicable, attach proof of school attendance for students aged 19 or over.
4. In the Provider Information section, input the names and addresses of both the examiner and dispenser. Ensure that their state license numbers and phone numbers are also included.
5. List all services received in the Service section. For each service (e.g., eye examination, lenses), enter the date of service and amount charged.
6. Finally, complete the Member/Employee Certification by signing and dating the form to confirm accuracy before submission.

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