paid denied pended direct reimbursement claim form reimbursement claim form important information: 1

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield is an independent licensee of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

From the CareFirst BlueCross BlueShieldfamily of health care plans.

FOR INTERNAL USE ONLY Auth #: __________________________________ Paid o Denied o Pended o

Direct Reimbursement Claim FormImportant 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. Only services listed on this form will be considered for

reimbursement. 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. If the form is incomplete, additional information may be required. This may result in a delay of payment for eligible benefits.

4. All claims must be submitted within one (1) year from the date of service, failure to do so will result in denial of reimbursement. 5. Please submit claim reimbursement for each patient on a separate claim form.6. Please note that the members (or employees or authorized persons) signature is required on this form. 7. Mail completed claim form to: Vision Care Processing Unit, P.O. Box 1525, Latham, NY 12110. 8. The completion and submission of this form does not guarantee eligibility for benefits. Please verify your coverage with your benefits

office or call 1-800-783-5602 or visit www.davisvision.com. The patient is responsible for the costs of all treatment and materials provided.

Member/Employee Information *Your Member Identification No. is the number by which the company that sponsors your vision care benefits identifies you.(PLEASE PRINT CLEARLY) Member Name: ___________________________________________________ First Middle Initial Last

Member Identification No.*: ___________________________

Mailing Address: __________________________________________________________________________________________________________ Street City State Zip Business Phone: _______________________________________________ Area Code

Home Phone: _______________________________________ Area Code

Patient Information

Patient Name: ___________________________________________________________ First Middle Initial Last

Relationship: o Member o Spouse o Child DOB: ____________

Provider InformationExaminer Dispenser

Name: _____________________________________________________ Name: _____________________________________________________

Address: ___________________________________________________ Address: ___________________________________________________

City: _____________________________ State: _______ Zip: _________ City: _____________________________ State: _______ Zip: _________

State License Number: _________________________________________ State License Number: _________________________________________

Phone Number: ______________________________________________ Phone Number: ______________________________________________

Provider Signature: ___________________________________________ Provider Signature: ___________________________________________

Service Date of Service Amount

1. Eye Examination OD o MD o

2. Frames

3. Single Vision Lenses

4. Bifocal Lenses

5. Trifocal Lenses

6. Contact Lenses Single Vision o Bifocal o

7. Cataract S.V. Lenses

8. Cataract Bifocal Lenses

9. Medically Necessary Contact Lenses

( / / ) $

( / / ) $

( / / ) $

( / / ) $

( / / ) $

( / / ) $

( / / ) $

( / / ) $

( / / ) $ Total $

Member/Employer Certification 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 provisions. Additionally, I have read and understand the Fraud Statement on the back of this form

Member/Employee or authorized persons signature Date

Required

CL00006 10/12

FRAUD STATEMENT

Any person who knowingly and with intent to defraud and deceive any insurance company submits an insurance application or statement of claim containing any false, incomplete or misleading information may be subject to civil or criminal penalties, depending upon state law.

In Florida, any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an insurance application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

In Maryland, any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

In New Jersey, any person who includes any false or misleading information on an application for insurance is subject to criminal and civil penalties.

In New York, applicants for Accident and Health Insurance: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

In Kentucky and Pennsylvania, any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

In 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.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

Registered trademark of CareFirst of Maryland, Inc.

Notice of Nondiscrimination and Availability of Language Assistance Services

CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. CareFirst:

Provides free aid and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, please call 855-258-6518. If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator. Civil Rights Coordinator, Corporate Office of Civil Rights Telephone Number 410-528-7820

Mailing Address P.O. Box 8894 Baltimore, Maryland 21224

Fax Number 410-505-2011

Email Address [email protected] You can file a grievance by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

mailto:[email protected]://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html



Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates

and you may need to take action by certain deadlines. You have the right to get this information and assistance in

your language at no cost. Members should call the phone number on the back of their member identification card.

All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent

answers, state the language you need and you will be connected to an interpreter.

(Amharic) -

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aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling

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855-258-6518 y esperar la grabacin hasta que se les indique que deben presionar 0. Cuando un agente de seguros

responda, indique el idioma que necesita y se le comunicar con un intrprete.

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mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta ozi na enyemaka a nass g na

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Deutsch (German) Achtung: Diese Mitteilung enthlt Informationen ber Ihren Versicherungsschutz. Sie kann

wichtige Termine beinhalten, und Sie mssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben

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Franais (French) Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates

importantes peuvent y figurer et il se peut que vous deviez entreprendre des dmarches avant certaines chances.

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employ(e) rpondra, indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interprte.

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paid denied pended direct reimbursement claim form reimbursement claim form important information: 1

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