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.

QuestionAnswer
Form NameVision Claim Transmittal Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesunited healthcare vision claim form, united healthcare vision reimbursement form, united healthcare reimbursement form vision, uhc vision out of network claim form

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:

 

 

Last Name:

 

 

 

First Name:

 

 

 

 

 

 

Sex M

F

Relationship to Member:

 

 

 

 

 

 

City

 

 

First

 

 

 

MI:

 

 

Name:

 

 

 

 

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

Code:

 

 

 

MI:

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

Full Time Student

 

School Name:

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

C. ACCIDENT INFORMATION:

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.

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