1800 Ninth Avenue PO Box 91015 Seattle, WA 981119115VISION CLAIM FORM Use this form to submit reimbursement requests for services from a nonnetwork provider or for the purchase of prescription contact.
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the WA HCA Form 02324UMP online
The WA HCA Form 02324UMP is essential for submitting reimbursement requests for services from non-network providers, along with purchases of prescription contact lenses or eyeglasses. This guide provides users with detailed, step-by-step instructions to effectively complete the form online.
Follow the steps to successfully fill out the WA HCA Form 02324UMP online.
- Press the ‘Get Form’ button to obtain the form and open it in your editor.
- In section 1, enter the UMP identification number, including any alpha characters, along with your personal details.
- For section 2, provide the patient's last name, first name, middle initial, date of birth, sex, relationship to the subscriber, and daytime phone number.
- Complete the subscriber's information, which includes their first name, last name, and group name and number.
- Move to section 3 to detail the examining physician or optometrist's information. Fill out the date of service, the professional's name, address, diagnosis code, and charges.
- For section 4, input supplier information including the date ordered and delivered, along with charges for lenses or glasses.
- Ensure all bills are itemized and attached, verifying that all necessary fields in the form are completed before submission.
- Finally, sign the form in section 5, ensuring the signature aligns with the information provided, and submit your completed claim.
Complete your WA HCA Form 02324UMP online today for a smoother reimbursement process.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
Seattle, WA 98111-9115. VISION ... Note: This form may be used for claims for PEBB Uniform...
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.
This form is available in several versions. Select the version you need from the drop-down list below.