United Healthcare Routine Vision Claim Form
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1ROUTINE VISION CLAIM FORM
Claim Address:
UnitedHealthcare
PO Box 740800
Atlanta, GA 30374-0800
Employer Name:
State of Maryland
Select Policy Number
o Choice Plus # 714569
o Select EPO # 716451
o Options PPO # 716450
Vision Care Providers – please make sure you have indicated the patient’s date of service, circled the appropriate procedure codes and filled
in the charge amounts for each code in Section C prior to submitting this claim. If this is a Pediatric vision claim, payment for a network
provider will be based on contract rate, if out of network reasonable and customary rates will apply.
A. MEMBER/EMPLOYEE INFORMATION (Please include your member ID on all documentation):
Member #
Last
First
MI:
Name:
Name:
Home Address
City
State
Zip
Code:
B. PATIENT INFORMATION:
Last Name:
First Name:
MI:
Date of Birth:
Sex
M
F
Relationship to Member:
C. THIS SECTION TO BE COMPLETED BY PROVIDER
PLEASE CHECK APPROPRIATE BOXES AND INDICATE APPLICABLE CHARGES:
Date of Purchase:________________________________________
Diagnosis: V720
L
E
Single Vision
V2101
$_____________________
Date of Exam: _______________________________
e
x
Bifocals
V2200
$_____________________
New Patient
92002
$_______________
n
a
Trifocals
V2300
$_____________________
92004
$_______________
s
m
Lenticular
V2121
$____________________
Established Patient
92012
$_______________
e
s
Bifocal Double
V2200-50 $____________________
92014
$_______________
s
Aphakic- glass
V2199
$____________________
Refraction
92015
$_______________
Aphakic- plastic V2199
$____________________
92310
$_______________
Aphakic- aspheric V2410
$____________________
Other
________
$_______________
Other
_______
$____________________
Date of Purchase: ____________________________________
Date of Purchase:_________________________________________
F
C
Standard
V2020
$______________
PMMA
V2500
$_____________________
o L
r
-
Other
________
$______________
Gas Permeable
V2510
$_____________________
n e
a
Hydrophilic
V2520
$_____________________
t
n
m
Scleral
V2530
$_____________________
a s
e
Other
_______
$_____________________
c e
s
t
t
s
Complete below if Contact Lenses are medically required:
Date of cataract Surgery______
Visual Acuity before ______ after ________lenses.
Would glasses correct Visual Acuity to at least 20/70 in the better eye? Yes or No
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 No :_________________________
Must be Furnished
Date:
Degree/Title:
NPI ___________________
Under Authority of
Employee ID No.: __________________
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:
G. AUTHORIZATION
Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a
criminal act punishable under law and may be subject to civil penalties.
Subscriber Signature_________________________________________________________Date_______________________Daytime Phone__________________
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