VISION CLAIM TRANSMITTAL
Claim Address: UnitedHealthcare PO Box 740800 Atlanta, GA 30374-0800 Employer Name: Princeton University Group (Policy) Number: 196484
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): Member # (SSN) Last First Name: Name: Home Address City B. PATIENT INFORMATION: Last Name: Sex M F
MI: State Zip Code: Date of Birth: School Name:
First Name:
MI: Full Time Student Yes No
Relationship to Member:
C. ACCIDENT INFORMATION: Work Accident? Yes No How did the accident occur: D. OTHER INSURANCE Is the patient covered by another insurance plan? Yes Name of person Carrying other insurance: SSN #: Policy Number: E.
Auto Accident? Yes
No
Date Accident Occurred: /
/
No
If yes, please complete the following: Date of Birth: / Name of the Other Insurance Carrier Employer Name: /
THIS SECTION TO BE COMPLETED BY PROVIDER PLEASE CHECK APPROPRIATE BOXES AND INDICATE APPLICABLE CHARGES: Date of Purchase:________________________________________ Diagnosis: V720 L Single Vision V2101 $_____________________ If the member purchases contacts online, please check off the e Bifocals V2200 $_____________________ appropriate box in the “Contact Lenses” section. Please also provide n Trifocals V2300 $_____________________ doctor’s name, address, and phone number in space provided. s e s F ra m e s Date of Purchase: ____________________________________ Standard V2020 $______________ Deluxe V2025 $______________
C o n t a c t
L e n s e s
Date of Purchase:_________________________________________ PMMA V2500 $_____________________ Gas Permeable V2510 $_____________________ Hydrophilic V2520 $_____________________ Scleral V2530 $___________________ _
Description: Total Charges Name of Provider who Performed the Services: Address: Provider’s Signature: Date:
$
Amount Paid by the Employee Phone (Area Code): City-State-Zip Code:
$
Degree/Title:
Tax ID No.:_____________________________ Employee ID No.: _____________________
Must be Furnished Under Authority of 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:
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.