Vision Claim Transmittal Form – Fill Out and Use This PDF

A Vision Claim Transmittal Form is a document that informs your vision insurance provider of the procedures you have undergone and any office charges.

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Vision Claim Transmittal Form PDF Details

The Vision Claim Transmittal Form is a government-provided form used to submit a claim for reimbursement of vision care services. The form can be used to request reimbursement for costs incurred for both medical and optical services, including eyeglasses, contact lenses, and eye surgery. The form must be filled out in full and include all required documentation before it can be processed. Reimbursement amounts are based on the type of service provided and the patient's current insurance coverage. For more information on how to submit a Vision Claim Transmittal Form, please visit our website or contact us toll-free at 1-800-MEDICARE (1-800-633-4227).

The table offers details about the vision claim transmittal form. It's a good idea that you read this information before you begin filling out the file.

Question	Answer
Form Name	Vision Claim Transmittal Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	72
Avg. time to fill out	14 min 58 sec
Other names	united healthcare vision claim form no download needed, united healthcare vision out of network claim form, united healthcare reimbursement form vision, unitedhealthcare vision claim form

12

Form Preview Example

VISION CLAIM TRANSMITTAL

Claim Address:

UnitedHealthcare

PO Box 740800 Atlanta, GA 30374-0800

Employer Name: North Jersey Health Insurance Fund

Group (Policy) Number: 705996

Vision Care Providers – please make sure you have indicated the patient’s diagnosis, date of service, and circled the appropriate procedure codes in Section E prior to submitting this claim.

A.MEMBER/EMPLOYEE INFORMATION (Please include your member ID on all documentation):

	Member # (SSN)			Last
				Name:
	Home Address
	B. PATIENT INFORMATION:
	B. PATIENT INFORMATION:
	Last Name:				First Name:

	Sex M	F	Relationship to Member:

City

		First					MI:
		Name:
				State			Zip
							Code:
			MI:			Date of Birth:
			MI:			Date of Birth:

Full Time Student					School Name:
Yes			No

C. ACCIDENT INFORMATION:

Work Accident? Yes				No
Work Accident? Yes				No

How did the accident occur:

Auto Accident? Yes

No

Date Accident Occurred:

//

D.OTHER INSURANCE Is the patient covered

by another insurance plan? Yes

No

If yes, please complete the following:

Name of person		Date of Birth:
Carrying other insurance:		/	/
SSN #:	Name of the Other
	Insurance Carrier
Policy Number:	Employer Name:

E. THIS SECTION TO BE COMPLETED BY PROVIDER

PLEASE CHECK APPROPRIATE

BOXES AND INDICATE APPLICABLE CHARGES:

E

Diagnosis: V720

L

Date of Purchase:________________________________________

Single Vision

V2101

$_____________________

x

Date of Exam: ____ ___________________________

e

Bifocals

V2200

$_____________________

a

New Patient

92002

$_______________

n

Trifocals

V2300

$_____________________

m

92004

$_______________

s

Lenticular

V2121

$_________________

s

Established Patient

92012

$_______________

e

92014

$_______________

s

Refraction

92015

$_______________

92310

$____________ _

F

Date of Purchase: ____________________________________

C

Date of Purchase:_________________________________________

Standard

V2020

$______________

PMMA

V2500

$_____________________

r-

o

L

Deluxe

V2025

$______________

Gas Permeable

V2510

$_____________________

n

e

a

Hydrophilic

V2520

$_____________________

t

n

m

Scleral

V2530

$___________________ _

a

s

e

c

e

s

t

s

Description:

Total Charges

$

Amount Paid by the Employee

$

Name of Provider who Performed the Services:

Phone (Area Code):

Address:

City-State-Zip Code:

Provider’s Signature:

Tax ID

Must be Furnished

No.:_____________________________

Date:

Degree/Title:

Employee ID No.: _____________________

Under Authority of

Law

F. ASSIGNMENT OF BENEFITS

Please sign below only if you want UnitedHealthcare to pay benefits directly to the provider of vision service:

Patient Signature:	Member Signature:	Date:

NOTE: Please do not attach any receipts or bills to this form. Make sure form is completely filled out and mail only this form to the above address.

How to Edit Vision Claim Transmittal Form Online for Free

It really is not hard to prepare the united healthcare reimbursement form vision. Our editor was created to be enable you to fill in any document swiftly. These are the four steps to take:

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The PDF template you plan to fill out will consist of the next sections:

part 1 to writing united healthcare vision reimbursement form

You have to enter the crucial information in the Date, of, Exam Lent, i, cula, rV Phone, Area, Code, City, State, Zip, Code TaxI, D, No, Employee, ID, No Must, be, Furnished Under, Authority, of, Law Date, and Degree, Title area.

stage 2 to filling out united healthcare vision reimbursement form

You will have to provide some particulars inside the box Member, Signature and Date.

Finishing united healthcare vision reimbursement form step 3

Step 3: Press "Done". You can now export your PDF document.

Step 4: To prevent yourself from possible upcoming complications, please be sure to have as much as a pair of copies of each and every file.

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