To submit the Vision Transmittal Form, ensure all fields are accurately filled and required documentation is attached. Send the completed form to UnitedHealthcare via mail at PO Box 30555, Salt Lake City, UT 84130. For any inquiries, contact the benefit administrator. Ensure to keep a copy for your records. Prompt submission ensures timely processing of your claim.

There are no specific important dates applicable for this form in 2024 and 2025. However, it is important to submit the form promptly after incurring the vision expenses to ensure timely processing of your claim.

The Vision Transmittal Form serves as a tool for submitting vision claims to UnitedHealthcare. When filled out accurately and completely, it ensures that your vision expenses are reimbursed promptly. The form collects essential information about the patient, subscriber, provider, and the services received, allowing UnitedHealthcare to process the claim efficiently. The form includes several sections that need to be completed either by the patient or by the provider. These sections capture essential details such as patient information, vision coverage, diagnosis, and the services provided. Accurate and thorough completion of this form is crucial for the timely and successful processing of your vision claim. Patients should ensure that their personal and vision coverage details are correctly entered, while providers should accurately document the services rendered and the associated charges. Maintaining clarity and legibility throughout the form helps to prevent any delays or issues in claim processing, ensuring that the benefits are received without unnecessary complications.

• 1. Patient Information: Includes fields for patient’s last name, first name, date of birth, and relationship to the insured.
• 2. Subscriber/Employee Information: Collects details such as last name, home address, first name, school name, subscriber number or SSN, employer name, city, state, and policy number.
• 3. Other Vision Coverage: Fields to fill out if the patient has additional vision coverage, including the name of the other insurance carrier and relevant details.
• 4. Provider Information: Section for providers to fill out, including diagnosis, service description, charges, provider’s name, and signature.
• 5. Assignment of Benefits: Includes subscriber signature and date fields to authorize payment directly to the provider if the bill has not been paid in full.

Failing to submit the Vision Transmittal Form may result in delays or denial of your vision claim.

• Claim Delays: Delays in claim processing can occur, leading to slower reimbursement.
• Claim Denial: Your vision claim may be denied without proper documentation.
• Further Documentation Requests: You may be contacted for additional information, causing further delays.

• 1. Regular Vision Checkups: Submit claims for routine vision exams.
• 2. Prescription Glasses: Use the form to claim expenses for prescription glasses.
• 3. Contact Lenses: File a claim for contact lens expenses.
• 4. Vision Therapy: Submit claims for vision therapy sessions.
• 5. Surgical Procedures: Use the form for claims related to vision-related surgical procedures.