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 |
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Form Name | Vision Claim Transmittal Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | united healthcare vision claim form, united healthcare vision reimbursement form, united healthcare reimbursement form vision, uhc vision out of network claim form |
VISION CLAIM TRANSMITTAL
Claim Address:
UnitedHealthcare
PO Box 740800 Atlanta, GA
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):
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Member # (SSN) |
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Last |
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Name: |
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Home Address |
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B. PATIENT INFORMATION: |
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Last Name: |
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First Name: |
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Sex M |
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Relationship to Member: |
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First |
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MI: |
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Name: |
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State |
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Zip |
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Code: |
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MI: |
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Date of Birth: |
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Full Time Student |
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School Name: |
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Yes |
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No |
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C. ACCIDENT INFORMATION:
Work Accident? Yes |
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No |
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How did the accident occur:
Auto Accident? Yes
No
Date Accident Occurred:
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D.OTHER INSURANCE Is the patient covered
by another insurance plan? Yes
No
If yes, please complete the following:
Name of person |
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Date of Birth: |
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Carrying other insurance: |
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SSN #: |
Name of the Other |
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Insurance Carrier |
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Policy Number: |
Employer Name: |
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E. THIS SECTION TO BE COMPLETED BY PROVIDER |
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PLEASE CHECK APPROPRIATE |
BOXES AND INDICATE APPLICABLE CHARGES: |
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E |
Diagnosis: V720 |
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Date of Purchase:________________________________________ |
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Single Vision |
V2101 |
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$_____________________ |
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Date of Exam: ____ ___________________________ |
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e |
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Bifocals |
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V2200 |
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$_____________________ |
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New Patient |
92002 |
$_______________ |
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n |
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Trifocals |
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V2300 |
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$_____________________ |
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m |
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92004 |
$_______________ |
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s |
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Lenticular |
V2121 |
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$_________________ |
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Established Patient |
92012 |
$_______________ |
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e |
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92014 |
$_______________ |
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s |
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Refraction |
92015 |
$_______________ |
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92310 |
$____________ _ |
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Date of Purchase: ____________________________________ |
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Date of Purchase:_________________________________________ |
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Standard |
V2020 |
$______________ |
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PMMA |
V2500 |
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$_____________________ |
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Deluxe |
V2025 |
$______________ |
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Gas Permeable |
V2510 |
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$_____________________ |
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Hydrophilic |
V2520 |
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$_____________________ |
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Scleral |
V2530 |
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$___________________ _ |
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Description: |
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Total Charges |
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$ |
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Amount Paid by the Employee |
$ |
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Name of Provider who Performed the Services: |
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Phone (Area Code): |
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Address: |
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Provider’s Signature: |
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Tax ID |
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Must be Furnished |
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No.:_____________________________ |
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Date: |
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Degree/Title: |
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Employee ID No.: _____________________ |
Under Authority of |
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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: |
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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.