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Loading...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