Get Regence Uniform Vision Claim Form

Filing a claim for vision-related expenses can be straightforward with the right guidance. This guide will help you complete the Regence Uniform Vision Claim Form online efficiently.

Follow the steps to successfully fill out your Regence claim form.

1. Click ‘Get Form’ button to obtain the form and open it in your editing tool.
2. Begin by entering the employee or retiree information. Fill out the UMP Identification Number, the patient's last and first name, their date of birth (mm/dd/yyyy), and sex. Indicate the relationship of the patient to the subscriber.
3. Proceed to the patient information section where you can also include the subscriber’s last name, first name, group name, and group number.
4. In the examining physician or optometrist information, provide the date of service, services rendered, diagnosis code, and charge. Ensure that the physician's name, address, and telephone number are listed.
5. Complete the supplier information section. This will require detail regarding the lenses, glasses, frames, and their respective charges. If necessary, attach a copy of the prescription.
6. Sign the release information. This section authorizes the release of medical information necessary to process the claim. Ensure to sign and date this section correctly.
7. Review all the information you have provided for accuracy. Attach itemized bills that include necessary details such as the patient’s name, date of service, diagnosis, and charges.
8. Once completed, save changes, and prepare to download, print, and share the form as needed. Submit the claim form to the specified address or fax number.

Complete your vision claim form online today for an easy and efficient reimbursement process.