Get Wa Uniform Medical Plan Form Pd001-ump1 2020-2025

The WA Uniform Medical Plan Form PD001-UMP1 is essential for submitting reimbursement requests for services received from non-network providers. This guide will help users navigate through the process of filling out the form online, ensuring they provide all necessary information accurately.

Follow the steps to complete the form online:

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the UMP identification number at the top of the form, followed by the patient's last name, first name, middle initial, date of birth, and sex.
3. Next, indicate the patient's relationship to the subscriber by selecting the appropriate option: self, spouse or certified domestic partner, or dependent.
4. Enter the daytime phone number of the patient for contact purposes.
5. Proceed to fill out the subscriber's last name, first name, and middle initial, along with the group name and group number.
6. In the other insurance information section, specify if the patient or any family members are covered by another plan by selecting yes or no for medical, vision, dental, and prescription coverage.
7. If there is other coverage, complete the subsequent questions about the type of coverage, specifying whether it is group or individual.
8. Indicate if the patient or any family members are covered by Medicare, and if yes, specify the parts that apply.
9. Provide information about other group insurance, including the subscriber's name, ID number, relationship to the plan, date of birth, and address for submitting claims.
10. Confirm who the coverage is for, selecting from the options available such as subscriber, spouse/DP, child(ren), or family.
11. If applicable, indicate the subscriber’s employer and the effective date of the plan.
12. If any services were paid for in cash, describe the type of service received.
13. Finally, certify that all information is correct by signing the form and dating it before submission.
14. Users can save changes, download, print, or share the completed form as needed.

Complete your WA Uniform Medical Plan Form PD001-UMP1 online today for a smooth reimbursement process.