Christian Casey LLC d/b/a Sean John (House of Z) Vision Care Service Record (This form to be maintained by the provider’s office) SECTION I - PROVIDER/PATIENT SECTION
SECTION II - COVERAGE SECTION
Member ID No.: _____________________________________ Patient Name:
Provider’s Name: _____________________________________ Provider’s No.:
Authorization No.: ____________________________________ Authorization Date: ___________________________________
A. Examination: Yes No 1a. Was examination comprehensive? Yes No 1b. Was dilation performed? Yes No 1c. Was this a new patient? Yes No 1d. Primary Diagnosis code:______________________________ Secondary Diagnosis code (if any): ____________________ B. Spectacle lenses provided: (check all that apply) Patient’s
2. Single Vision C. Contact Lenses: Plan Supplied: Formulary A Provider Supplied: Cosmetic
(prior approval required)
D. Frame Provided: Plan
Prefix SJP $ 0.00 $ 0.00 $ 0.00
$ 0.00 $ 0.00
$ 0.00 $ 0.00
Plan Description: Eye examination, frame and spectacle lenses or contact lenses (in lieu of eyeglasses). Medically necessary contact lenses may be provided with prior approval. SECTION IV - ALLOWANCE SECTION
SECTION III - SERVICE SECTION
Eye examination Frame Spectacle lenses Contact Lenses: Formulary A Formulary B
Prefix SJN $ 0.00 $ 0.00 $ 0.00
SECTION VI - 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 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. 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. Authorized Signature ______________________________ Invoice No. ______________________________________
Medically Necessary Contact lenses
Covered in full (prior approval required)
SECTION V - OPTIONS SECTION Patient charges for selected options. Additional dispense will be paid by Davis Vision. Patient Charge Option 5 SJN SJP Premier Included Included Frame Ultraviolet $12.00 Included Coating Scratch-Resistant $20.00 Included Coating Photochromic $20.00 Included Lenses Blended $20.00 Included Segments Intermediate $30.00 Included Vision Lenses Standard Progressive $50.00 Included Addition Multifocals Premium Progressive $90.00 Included Addition Multifocals Polycarbonate $30.00* Included Lenses Standard ARC $35.00 Included (anti-reflective coating) Premium ARC (anti-reflective coating) Ultra ARC (anti-reflective coating) Polarized Lenses High Index Lenses Plastic Photosensitive Lenses
Additional Dispense $ 5.00 $ 6.00 $10.00 $10.00 $10.00 $10.00 $30.00 $30.00 $20.00 $ 7.00
*No copayment/additional dispense for dependent children, monocular members and patients with Rx +/-6.00 or greater.
INSTRUCTIONS: 1. Participating provider must complete Sections I, III, V, and VIB. 2. Member or legal guardian should complete and sign Section VIA 3. All services rendered should be recorded on a single form. 4. Authorization is valid for 45 days. If expired, call 1-800-773-2847 prior to rendering services. 5. Completed forms must be maintained for a period of not less than seven (7) years. 6. 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.
You have specific ERISA appeals rights regarding your vision care benefits. These rights may be obtained in detail by contacting Davis Vision at 1-800-999-5431 or writing to: Quality Assurance Department P. O. Box 1525 Latham, NY 12110 Appeals must be made within 180 days of the date of service.