Loading
Get Regence Uniform Medical Claim Form 2020-2025
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Regence Uniform Medical Claim Form online
Filing a claim for reimbursement can be a streamlined process if you know how to correctly fill out the Regence Uniform Medical Claim Form. This guide provides step-by-step instructions to assist you in completing the form efficiently.
Follow the steps to complete the Regence Uniform Medical Claim Form.
- Click ‘Get Form’ button to obtain the necessary document and open it in your preferred editor.
- Begin with Section 1, where you will input the employee or retiree information. This includes the UMP identification number, patient's last and first name, date of birth, sex, and relationship to the subscriber. Ensure to provide a daytime phone number and the subscriber's details.
- Move to Section 2, which requires patient information. Fill in the same details pertaining to the patient, including their relation to the subscriber.
- In Section 3, provide the examining physician or optometrist information. Enter the date of service, services rendered, physician's name, address, and phone number. Include specific diagnosis and procedure codes and confirm whether refraction is included.
- Acknowledge Section 4 by filling in the supplier information. This section may require the provider's input or an attached prescription to ensure all information is complete for processing the claim.
- Finally, before submission, review all sections for accuracy. When satisfied, sign the completed form in the designated area, indicating your authorization for releasing medical information necessary for processing the claim.
- Submit the claim form to Regence BlueShield using the provided address or by fax. Retain copies of the completed form and all attached itemized bills for your records.
Complete your Regence Uniform Medical Claim Form online today for efficient claim processing.
Related links form
School employees in Washington state enjoy various benefits, including health insurance through plans like UMP. These benefits often cover medical, dental, and vision care, contributing to the overall well-being of employees and their families. For any medical claims, including UMP services, using the Regence Uniform Medical Claim Form will ensure your claims are properly filed.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.