Highmark Blue Vision Care Service Record printable pdf download

Highmark Blue Shield

Fashion Focus Limited Plan

Vision Care Service Record

(A copy of this form to be maintained by the provider’s office)

To claim reimbursement for services provided in conjunction with this plan, you must either fax the

completed form to Davis Vision at 1-888-328-4761 or mail it to Davis Vision, P.O. Box 1525, Latham, NY,

12110. Failure to do so will significantly delay processing of payment to your office.

INSTRUCTIONS

SECTION I - PROVIDER/PATIENT SECTION

1. Provider: Complete Sections I, III, and IV-B. Make sure

Member Name:

_____________________________________________

all applicable areas have been filled in.

Member ID No.: _____________________________________________

2. Member or legal guardian should complete and sign

Section IV-A.

Patient Name:

_____________________________________________

3. All services rendered should be recorded on a single form.

Relationship:

Member __ Spouse __ Child __

4. Authorization is valid until the end of the current month.

Provider’s Name: _____________________________________________

If expired, call 1-800-773-2847 prior to rendering services.

Provider’s No.:

_____________________________________________

5. Completed forms must be maintained for a period of not

Authorization No.: HZB ________________________________________

less than seven (7) years.

Authorization Date:____________________________________________

6. Tennessee state law stipulates that it is a crime to

knowingly provide false, incomplete or misleading

SECTION II - COVERAGE SECTION

information to an insurance company for the purpose

of defrauding the company. Penalties include

Plan Description:

imprisonment, fines and denial of insurance benefits.

Allowance toward eye examination, spectacle lenses and a frame or

contact lenses (in lieu of eyeglasses) as outlined below.

SECTION III - SERVICE SECTION

Please complete the Date of Service, U&C, and Patient Pays sections for all services received. Incomplete information

may result in significant delay of payment.

Service

Date of Service

U&C

Maximum

Patient Pays

Allowance

(if positive)

Eye Examination

(

)

$29.04

Frames

(

)

$20.57

Single Vision Lenses (one pair)

(

)

$29.04

Bifocal Lenses (one pair)

(

)

$43.56

Trifocal Lenses (one pair)

(

)

$58.08

Lenticular

(

)

$72.60

Elective Contact Lenses

(

)

$43.56

Progressive Lenses

(

)

$43.56

Total

SECTION IV- SIGNATURE SECTION

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 of the charges I am responsible for as outlined in Section III, and I bear the full responsibility for

payment of any charge associated with any of the items selected. TN RESIDENTS: Please see instruction 6 above.

Patient Signature ______________________________________________________Date of Service ________________________________________

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 above.

Authorized Signature____________________________________________________

You have specific ERISA appeals rights regarding your vision care benefits.

These rights may be obtained in detail by contacting Vision Member Services at 1-800-223-4795 or writing to:

Vision Member Services

P.O. Box 890035

Camp Hill, PA 17089-0035

Attention: Member Appeals

SR02138

12/2/11

Appeals must be made within 180 days of the date of service.