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Davis Vision Student Verfication Form

This document is a student verification form for a New York state vision plan. It requires dependent students aged 19-24 to submit proof that they are full-time students before receiving vision benefits. The form needs to be returned at least 10 days before a doctor appointment, and requires the student's name, date of birth, school information, the plan member's name and member ID number. The member signs to verify the student's dependent status and agrees to notify the plan of any changes.

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100 views1 page

Davis Vision Student Verfication Form

This document is a student verification form for a New York state vision plan. It requires dependent students aged 19-24 to submit proof that they are full-time students before receiving vision benefits. The form needs to be returned at least 10 days before a doctor appointment, and requires the student's name, date of birth, school information, the plan member's name and member ID number. The member signs to verify the student's dependent status and agrees to notify the plan of any changes.

Uploaded by

Ben
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NEW YORK STATE VISION PLAN

STUDENT VERIFICATION FORM

DEPENDENT STUDENT: Is defined as an unmarried child, who is a full-time student, covered through
age 24. A dependent must be considered a full-time student by the school attended.

Please return this form to Davis Vision, via email, Fax or US postal mail at least 10 days before
your doctor appointment for a dependent student age 19 thru 24.

The member ID is necessary for us to process any requests.

I certify that my dependent, _____________________, _________________ _______________

Printed Last Name Printed First Name Date Of Birth

Is unmarried, and is enrolled full time in an accredited secondary or preparatory school or college.
I agree to advise Davis Vision promptly of any changes in my child’s dependent student status.

Name of School: ____________________________ Location: ______________________

Semester Starts: ____________________ Semester Ends: ________________________

_____________________________, ________________________ ________________________

Enrollee’s Printed Last Name Enrollee’s Printed First Name Enrollee’s Member ID Number

_____________________________________ ____________________

Enrollee’s Signature Date

The member ID is necessary for us to process any requests.

Please return form to Davis Vision via one of the following methods:

1. Email to: nysvision@davisvision.com


2. FAX to the attention of “NYS Student Proof” at 1-800-292-9687
3. Mail to: Davis Vision
Attn: NYS Student Proof
PO Box 1501
Latham, NY 12110

Any person who knowingly and with the intent to defraud any company or other person files a statement of claim
containing any materially false information or conceals for the purpose of misleading, information concerning any fact
material thereto, commits a fraudulent act, which is a crime, and shall also be subject to civil penalty not to exceed
five thousand dollars and the stated value of the claims for each such violation.

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