Form C-53175 - Ppo/cmm Routine Vision Claim Form

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PPO/CMM Routine Vision Claim Form
PO Box 9291
Des Moines, Iowa 50306-9291
Clear Form
Member ID (include prefix and identification number)
Patient Last Name
First Name
Patients Street Address
City
State
Zip Code
Home Phone
Patients Gender
Patients Relationship to Member
Patients Date of Birth
c Self c Spouse c Child c Other
/
/
c M c F
(
)
Place of Service
Subscribers Name
Subscriber’s Date of Birth
/
/
I certify that the information given is complete and correct and that I am claiming benefits only for charges incurred by the patient named above. I authorize any health
care provider to release medical records to Wellmark Blue Cross and Blue Shield of Iowa when reasonably related to the health care claims submitted. If any law or
regulation requires additional authorization for release of medical records, I will give this authorization.
___________________________________________________________
Signed
Date
_____/_____/_____
Date of
Procedure
When “Other” is checked fully describe
Charges
services or supplies furnished
Services
Code
/
/
V2020
Frames
/
/
V2199
Single Vision Lens
/
/
V2299
Bifocal Lens
/
/
V2399
Trifocal Lens
/
/
V2781
Progressive Lens
/
/
V2599
Contact Lens (List Type)
/
/
S0500
Disposable Contact Lenses
/
/
Other Services
Routine examination including refraction; new
/
/
92002
patient
Routine examination including refraction;
/
/
92012
established patient
/
/
92310
Contact Lens Fitting
Total Charges
ADDITIONAL DIAGNOSIS
DIAGNOSIS
$0.00
Prior to 10/1/2015 — 10/1/2015 and after
V72.0
Z01.00
Phone Number
Tax ID Number
National Provider ID
(
)
Provider Name
Provider Street Address
City
State
Zip Code
C-53175 9/15

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