claim-form-vision.pdf.png
305 Downloads
0 0

Download United Healthcare Vision Claim Form, also known as Vision Plan Out-of-Network Claim Form. If you are already working with United Healthcare, in Network Vision, you will not need to file a claim inasmuch as your in Network provider will file your claims for you.

However, should you decide to use a provider who is out-of-network, although UHC will pay a portion, they will not pay as much as if you were working with in-network providers. Complete this form to claim the portion available to you, after you have been paid out of pocket.

How To Write

Step 1 – Section 1 – Complete the employee and patient information

  • Today’s Date mm/dd/yyyy
  • Date Of Service mm/dd/yyyy
  • Employee’s Name
  • Employee’s Unique Identification Number
  • Address Where Check Should Be Mailed
  • Address
  • City
  • State
  • Zip Code
  • Patient’s Name
  • Patient’s Relationship to Employee (check one)
  • Patient’s Of Birth mm/dd/yyyy

Step 2 – Section 2 – Please complete services and materials received. You must provide the costs paid. Costs paid must match submitted receipt(s).

  • Please Note: Read the information located in section 2 with regard to receipts and reimbursement

Step 3 – Section 3 – Exam

  • Eye/Vision Exam
  • Dollar Amount Paid

Step 4 – Section 4 – Complete this area for glasses OR contacts

  • Glasses – See the information available in the “Glasses” block, click inside the circle of what you have purchased and place the price behind “paid” in the same block.
  • Contacts – Provide what was paid for contact fitting and exam as well as the cost of the contact lenses
  • Date mm/dd/yyyy

Step 5 – Return this form with a copy of your paid, itemized receipt(s) to:

  • UnitedHealthcare Vision
  • ATTN: Claims Department
  • P.O. Box 30978
  • Salt Lake City, UT 84130
  • Fax: (248) 733-6060

 

 

Preview

Adobe PDF