1) Use this form for out-of-network providers. In-network providers will bill Davis Vision directly.

2) The participant must fill out the section labeled "Employee" and "Patient." The vision care provider must fill out section labeled "Provider." If the provider prefers to give you an itemized bill that you can attach to the form, this is acceptable but be sure it contains all of the required information.

3) Please mail the completed claim form to:

Vision Care Processing Unit
PO Box 1525
Latham, NY 12110

4) Davis Vision will then process your claim for payment. If additional information is required in order to process the claim, Davis Vision will contact you. Please note that Davis Vision can only make payment to the participant.