a Sean John (House of Z) - Davis Vision

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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

Member Name:

SECTION II - COVERAGE SECTION

_____________________________________

Plan Level:

Premier

Member ID No.: _____________________________________ Patient Name:

_____________________________________

Relationship:

Member __

Spouse __

Copayments:

Child __

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

Bifocal †

Trifocal †

† Formulary B

†

† Medically Necessary

†

(prior approval required)

D. Frame Provided: Plan †

Patient’s †

Provider’s

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

1. Plan †

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. ______________________________________

Frame

Spectacle Lenses

Contact Lenses

Medically Necessary Contact lenses

$50.00 (wholesale)

N/A

$115.00

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

†

$48.00

Included

$ 7.00

†

$60.00

Included

$15.00

†

$75.00

Included

$25.00

†

$55.00

Included

$25.00

†

$65.00

Included

$25.00

*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.

SR00354 11/20/06

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.

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a Sean John (House of Z) - Davis Vision

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...

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