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Form 02324UMP1 (Rev. 1/16) VISION CLAIM FORM Use this form to submit reimbursement requests for services from a non-network provider or for the purchase of prescription contact lenses or eyeglasses. Please complete a separate form for each family member. The time limit for filing claims is one year from the date of service/purchase. Note: This form may be used for claims for Uniform Medical Plan, UMP Classic, or UMP CDHP. Most providers will bill directly and no claim form will be necessary. However, if you do incur expenses from a provider that does not bill the plan directly, you will need to complete sections 1, 2 and 5 of the claim form. Have your provider complete sections 3 and 4 (Physician or Supplier information) unless the itemized bill(s) include this information. 1. Complete the information below and on the back of this form. 2. Attach itemized bills, including patient’s name, date of service, diagnosis, procedures and charges. 3. Retain copies for your records. Receipts will not be returned. 4. Sign the completed form where indicated at the bottom of this page and submit the completed claim form to: Regence BlueShield Attn: UMP Claims PO Box 1106 Lewiston, ID 83501-1106 Or by fax to: 1-[PHONE REDACTED] Payments will be mailed to the address on file for the subscriber. You can verify your address by calling UMP Customer Service at 1-[PHONE REDACTED]. 1. EMPLOYEE/RETIREE INFORMATION 2. PATIENT INFORMATION UMP Identification Number (include alpha characters) Patient’s Last Name Patient’s First Name MI Patient’s Date of Birth Patient’s Sex: Male Female Patient’s Relationship to Subscriber: Self Spouse OR certified domestic partner (DP) Dependent Daytime Phone Number Subscriber’s Last Name Subscriber’s First Name MI Group Name Group Number 3. EXAMINING PHYSICIAN OR OPTOMETRIST INFORMATION Date of Service Services Rendered Refraction Included? Yes No Charge Physician’s or Optometrist’s Name, Address and Zip code Diagnosis code Procedure code Telephone Number Signature of Physician or Optometrist Date Signed 1800 Ninth Avenue PO Box 91015 Seattle, WA 98111-9115 - Continued on reverse - Uniform Medical Plan (mm/dd/yyyy) (xxx) xxx-xxxx (mm/dd/yyyy) (xxx) xxx-xxxx (mm/dd/yyyy) ---PAGE BREAK--- Form 02324UMP2 (Rev. 1/16) 4. SUPPLIER INFORMATION (To be completed by provider or attach a copy of the prescription) All sections must be fully completed before this claim will be processed or attach a copy of the prescription. Lenses for One Eye Both Eyes Date Ordered Date Delivered Glasses One Pair Two Pair Single Vision $ Bifocal $ Trifocal $ Lenticular $ $ Special Features Yes No (Extra Charge, if any) Plastic Lenses $ Oversize $ Tinting (of any kind) $ Blended focal $ Other $ Frames Existing $ New $ If new, why? Aphakic? Yes No TOTAL CHARGES (Including tax): $ Contacts: Therapeutic? Yes No Aphakic? Yes No Daily Wear Spherical Lenses Hard $ Soft $ Gas Permeable $ Daily Wear Toric Soft $ Gas Permeable $ Flexible Wear Soft $ Gas Permeable $ Other $ Supplier’s Name, Address and Zip code Tax ID Number (TIN) Telephone Number Signature of Physician or Optometrist NPI Date Signed 5. EMPLOYEE/RETIREE RELEASE INFORMATION Employee/Retiree/Patient/Authorized Person’s signature (read before signing). I authorize the release of any medical information necessary to process this claim from my provider of service or any insurance company involved in final benefit determination. If allowed by the participating Blue Cross or Blue Shield Plan, I direct payment to be made to: The provider of service The employee/retiree Signature Date It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance. (mm/dd/yyyy) (mm/dd/yyyy) 0 (xxx) xxx-xxxx (mm/dd/yyyy) (mm/dd/yyyy)