UnitedHealthcare Vision’ Vision Plan Out-of-Network Claim Form Please complete the employee and patient information Todays Date Date of Service Employer's Name Employees Unique Mention Number (SS¥) ‘Address where heck shouldbe maled state aP elaonsip Employee ies ra) set Odepenaart 10 complete services and materials received. You must provide the cen) Blea Noa: ects must shied oe froquonay your emp ne ha same er or seve ae atari purchased eve pa "tu il ace a erase ramus sed on Your ere Bam (O Eye/Vision Bram Paik S| Ser OR... | Complete below for contacts, ‘Glassos Contacts 2 Femes Paaes Contec Fting Exam Pai “Gtaseee LeneTypo Chex ovonet_____——_~([O Contact Lenses Paid $ (© _Shlewisoninees Paid O BHocalionses Pa § = ‘orn ena paca, O Titecallonses Pac O Lomicuarlonses Pad $ Employee Signature De Please retum this form with a copy of your pa, itemized receipt to: \Untedeatcare Vision AAT: lame Deparment PO, Box Sore Ss Le iy UT 84190 Fe a 736 aoe ‘Questions? You cn cal or Custom Service Deparment (80) 6983120