Maryland State Employees/retirees Routine Vision Service Form Page 2
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2Vision Form Instructions
Section 3: Assignment of benefi ts
This Vision Service Form must be accompanied by a
(if applicable)
receipt if paid by the member. This form must be used
If signed, payment will be made directly to physician
by you to fi le a claim for reimbursement or, if your
or health care practitioner. The member will be
provider accepts Assignment of Benefi ts, to assign
reimbursed only if acceptable proof of payment is
your benefi ts to the provider. NOTE: Claims must be
submitted with claim. Acceptable proof of payment
submitted within one year from date of service. Claims
includes cancelled check or receipt from the provider
received after that period will be denied. Additionally,
of service.
claims will be denied if you are found to be ineligible.
Section 4: Authorization
Section 1: Patient information
Your signature indicates agreement with the written
This section contains information which identifi es the
authorization in this section and certifi es that the
person who is eligible to receive services.
services as described were received by you or
1. Complete each block.
your dependent. Indicate date signed and daytime
2. Indicate the Member Number of the patient.
telephone number.
3. Complete employee information.
Mailing instructions (employee/physician or
Section 2: Physician/health care
health care practitioner)
practitioner information
Mail the completed Service Form and a copy of the
The provider (eye doctor or optician) must complete
receipt to:
this section.
UnitedHealthcare
1. Column 1: Enter the month/day/year that the service
P.O. Box 740800
was provided.
Atlanta, GA 30374-0800
2. Column 2: Enter amount charged for the service.
3. Complete the remaining provider information
requested (if applicable).
Submitting an incomplete form will result
4. If you (physician or health care practitioner) are to
in a delay in processing.
receive payment, the State of Maryland employee
will sign the Assignment of Benefi t section.
5. Be certain that all necessary patient and provider
For questions, call the dedicated
information has been completed.
State of Maryland Member Services
at 1-800-382-7513.
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