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Get Davis Vision Fax Number

Received by Davis Vision PRIOR APPROVAL REQUEST FORM Submit To Toll Free Fax 1-800-584-2329 Important PLEASE VERIFY MEMBER BENEFIT PRIOR TO SUBMITTING REQUEST. Patient Information Patient Name Patient DOB Member ID Number New Patient Yes No Member Name Group Employer Name Date of Service Provider Information Provider Name Please Print Provider Email Address Provider Panel Number Required Date of Request Provider Telephone Number Provider Fax Number Please Mark Services Requested Exam Only Eyeglasses only Low Vision Evaluation Exam Eyeglasses Repair/Replace Reason Contact Lens Evaluation Is there a medical condition related to this request Additional Exam Keratoconus Progressive Myopia Anisometropia Aphakia Pathological Myopia Post Cataract Date Last Surgery Diabetes Other Provider Comments Supporting Documents Attached Prescription Information Required Rx Glasses Contact Lenses OD VA OD / OS VA OS / Professional Fee Material Fee Low Vision Aids Both Old and New Prescription Must Be Completed Below for Requests Related to Changes in Rx Old Rx New Rx FOR DAVIS VISION USE ONLY PLEASE DO NOT WRITE BELOW THIS AREA Approved Date Authorization Number/Benefit Denied Date Reviewed By Signature Comments Additional Information Required Date Received CONFIDENTIALITY NOTE The information contained in the facsimile is confidential and intended for the use of the addressee shown above. Received by Davis Vision PRIOR APPROVAL REQUEST FORM Submit To Toll Free Fax 1-800-584-2329 Important PLEASE VERIFY MEMBER BENEFIT PRIOR TO SUBMITTING REQUEST. Patient Information Patient Name Patient DOB Member ID Number New Patient Yes No Member Name Group Employer Name Date of Service Provider Information Provider Name Please Print Provider Email Address Provider Panel Number Required Date of Request Provider Telephone Number Provider Fax Number Please Mark Services Requested Exam Only Eyeglasses only Low Vision Evaluation Exam Eyeglasses Repair/Replace Reason Contact Lens Evaluation Is there a medical condition related to this request Additional Exam Keratoconus Progressive Myopia Anisometropia Aphakia Pathological Myopia Post Cataract Date Last Surgery Diabetes Other Provider Comments Supporting Documents Attached Prescription Information Required Rx Glasses Contact Lenses OD VA OD / OS VA OS / Professional Fee Material Fee Low Vision Aids Both Old and New Prescription Must Be Completed Below for Requests Related to Changes in Rx Old Rx New Rx FOR DAVIS VISION USE ONLY PLEASE DO NOT WRITE BELOW THIS AREA Approved Date Authorization Number/Benefit Denied Date Reviewed By Signature Comments Additional Information Required Date Received CONFIDENTIALITY NOTE The information contained in the facsimile is confidential and intended for the use of the addressee shown above. If you are neither the intended recipient nor the employer agent responsible for delivering this message you are hereby notified that any disclosure copying distribution or taking of any action in reliance on the contents of this telecopy information is strictly prohibited* If you have received this telecopy in error please notify us by telephone to arrange for its return* GUR0003 Revised 9.

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