[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-288477-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-288477-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","sr02735-vision-insurance-claim-form","SR02735 - Vision Insurance Claim Form","","Vision insurance claim form covering the provider and patient member details, coverage plan level, service records, lenses and frames provided, and patient option charges. Includes examination indicators (comprehensive exam, dilation, new patient status), primary and secondary diagnosis codes, and pricing/discount schedules for spectacle and contact lenses plus frame allowances. Provides signature sections to certify accurate service details, authorization release of necessary information, and compliance with the Davis Vision Program, with TN-specific instruction notes and appeal and filing guidance.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/sr02735-vision-insurance-claim-form/288477/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/sr02735-vision-insurance-claim-form/288477.png","ImageObject",442,249,{"name":42,"@type":43},"Rizky","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":26},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What information is required in the provider/patient section?","Question",{"text":62,"@type":63},"It requires member name and member ID, patient name and relationship, provider name and provider number, and authorization information including authorization number and authorization date.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"How does the form handle examination and diagnosis details?",{"text":67,"@type":63},"It records whether the examination was comprehensive, whether dilation was performed, whether it was a new patient, and provides fields for primary and secondary diagnosis codes.",{"name":69,"@type":60,"acceptedAnswer":70},"What are the key instructions and deadlines for completing and submitting the form?",{"text":71,"@type":63},"The form instructs providers to complete specific sections and records services on a single form; authorization is valid for 21 days, and completed forms must be maintained for at least seven years. It also notes appeals rights must be filed within 180 days of the date of service.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},288477,1790195799,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":26,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":4},962085564807,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","CareFirVissinECxarcehSearvnicegReecPrordoducts  \n(This form to be maintained by the provider’s office)  \n| SECTION I - PROVIDER/PATIENT SECTION |\n| --- |\n| Member Name:   Member ID No.:   Patient Name:  \u003Cbr>Relationship: Member   Spouse   Child  \u003Cbr>Provider’s Name:  \u003Cbr>Provider’s No.:   Authorization No.: EXD  Authorization Date:   |\n\n\n| SECTION III-SERVICE SECTION |\n| --- |\n| A. Examination: Yes o No o 1a. Was examination comprehensive? Yes o No o\u003Cbr>1b. Was dilation performed? Yes o No o\u003Cbr>1c. Was this a new patient? Yes o No o\u003Cbr>1d. Primary Diagnosis code:   Secondary Diagnosis code (if any):   |\n| B. Spectacle Lenses Provided:*\u003Cbr>Member Pays:\u003Cbr>Single Vision o $35\u003Cbr>Bifocal o $55\u003Cbr>Trifocal o $65\u003Cbr>Lenticular o $110 |\n| C. Contact Lenses: Member Pays:\u003Cbr>Contact Lens Examination o 15% off U & C\u003Cbr>Conventional o 20% off U & C\u003Cbr>Disposable/planned replacement o 10% off U & C |\n| D. Frame Provided*:\u003Cbr>Member Pays\u003Cbr>Priced up to $70 retail o $40\u003Cbr>Priced above $70 retail o $40 plus 10% off the\u003Cbr>amount over $70 |\n\n\n| SECTION VI-SIGNATURE SECTION |\n| --- |\n| A. I certify that all of the services and materials indicated above as received are indicated accurately, and authorize the release of any medical or other information necessary to process this claim. Additionally, I certify that I have been informed of all additional items and costs as outlined in Sections IV and V, and I bear the full responsibility for payment of any charge associated with any of the items selected. I understand that Progressive Addition Lenses will be furnished upon my request and if I am unable to adapt to these lenses, standard bifocal lenses will be provided with no additional cost, however, the copayment (if any) for the Progressive Addition Lenses will not be refunded. TN RESIDENTS: Please see instruction 6 at right.\u003Cbr>Patient Signature   Date of Service  \u003Cbr>B. I certify that all services were provided by me or by authorized personnel, in compliance with the standards of the Davis Vision Program. TN PROVIDERS: Please see instruction 6 at right .\u003Cbr>Authorized Signature   Invoice No.   |\n\n\n| SECTION II-COVERAGE SECTION |\n| --- |\n| Plan Level: Hybrid Affinity\u003Cbr>Copayments: Eye examination $0\u003Cbr>Evaluation/fitting 15% off U&C\u003Cbr>Frame Discount only see section III\u003Cbr>Spectacle lenses Discount only see section III\u003Cbr>Contact Lenses: Discount only see section III\u003Cbr>Plan Description:\u003Cbr>Eye examination (including dilation), discount towards spectacle lenses and a frame or contact lenses in lieu of eyeglasses. |\n\n\n| SECTION IV-OPTIONS SECTION* |  |  |\n| --- | --- | --- |\n| Patient charges for selected options.\u003Cbr>(in addition to lens price) |  |  |\n| Option | R | Patient\u003Cbr>Charge |\n| Standard Progressive\u003Cbr>Lenses | o | $75 |\n| Premium Progressive\u003Cbr>Lenses | o | $125 |\n| Blended\u003Cbr>Invisible Bifocals | o | $20 |\n| High\u003Cbr>Index | o | $55 |\n| Polarized\u003Cbr>Lenses | o | $75 |\n| Glass\u003Cbr>Lenses | o | $18 |\n| Polycarbonate\u003Cbr>Lenses | o | $30 |\n| Scratch-Resistant\u003Cbr>Coating | o | $20 |\n| Standard ARC\u003Cbr>(anti-reflective coating) | o | $45 |\n| Ultraviolet\u003Cbr>Coating | o | $15 |\n| Solid\u003Cbr>Tint | o | $10 |\n| Gradient\u003Cbr>Tint | o | $12 |\n| Photochromic\u003Cbr>Lenses | o | $35 |\n| Plastic Photosensitive\u003Cbr>Lenses | o | $65 |\n| Intermediate Vision\u003Cbr>Lenses | o | $30 |\n\n*Special lens designs, materials, powers and frames may require  \nadditional cost. Prices represent maximum patient charges for the items listed.  \nINSTRUCTIONS:  \n1. Participating provider must complete Sections I, III, V, and VIB.  \n2. Member or legal guardian should complete and sign Section VIA.  \n3. All services rendered should be recorded on a single form.  \n4. Authorization is valid for 21 days. If expired, call 1-800-773-2847 prior to rendering services.  \n5. Completed forms must be maintained for a period of not less than seven (7) years.  \n6. Tennessee state law stipulates that it is a crime to knowingly provide false, incomplete or misleading information to an insurance ","cbCaii7PlXLTw0Tn","https://ap.wps.com/l/cbCaii7PlXLTw0Tn","pdf",46091,"English","# SECTION I - PROVIDER/PATIENT SECTION\n# SECTION II - COVERAGE SECTION\n# SECTION III - SERVICE SECTION\n# SECTION IV - OPTIONS SECTION\n# SECTION VI - SIGNATURE SECTION","[{\"question\":\"What information is required in the provider/patient section?\",\"answer\":\"It requires member name and member ID, patient name and relationship, provider name and provider number, and authorization information including authorization number and authorization date.\"},{\"question\":\"How does the form handle examination and diagnosis details?\",\"answer\":\"It records whether the examination was comprehensive, whether dilation was performed, whether it was a new patient, and provides fields for primary and secondary diagnosis codes.\"},{\"question\":\"What are the key instructions and deadlines for completing and submitting the form?\",\"answer\":\"The form instructs providers to complete specific sections and records services on a single form; authorization is valid for 21 days, and completed forms must be maintained for at least seven years. It also notes appeals rights must be filed within 180 days of the date of service.\"}]","SR02735 - Vision Insurance Claim Form | PDF",1789633527]