Unicare Vision Form

Com To Mail UniView Vision Attn Vision Claims P. O. Box 8504 Mason OH 45040-7111 Coverage is provided by UniCare Life Health Insurance Company. UniView Vision Out of Network Claim Form If you choose an out-of-network provider please complete the following steps prior to submitting the claim form to UniView Vision* Not all plans have out-of-network benefits so please consult your member benefits information to ensure coverage of services and/or materials from out-ofnetwork providers. Any missing or incomplete information may result in delay of payment or the form being returned* Please complete and send this form to UniView Vision within one 1 year from the original date of service by an out-of-network provider s office. When visiting an out-of-network provider you are responsible for payment of services and/or materials at the time of service. UniView Vision will reimburse you for authorized services according to your plan benefits. Check will be sent directly to a dependent if that dependent is over the age of 18. Subscriber Patient Please indicate to whom the reimbursement should be sent CHECK ONE Please complete all sections of this form to ensure proper benefit allocation* must be paid in full in order to receive benefits. Handwritten receipts must be on the provider s letterhead* Attach itemized paid receipts from your provider to the claim form* If the paid receipt is not in US dollars please identify the currency in which the receipt was paid* Sign the claim form where indicated* DATE OF SERVICE / Patient Information FIRST NAME LAST NAME MI STREET ADDRESS STATE CITY PHONE BIRTH DATE ZIP Plan Information SUBSCRIBER NAME PLAN NAME SUBSCRIBER ID Request For Reimbursement Please Enter Amount Charged* Remember to include itemized paid receipts. Exam Frames Lenses Contact Lenses includes fit and follow-up please submit all contact related charges at the same time If lenses were purchased please check type Single Bifocal Trifocal Progressive I hereby understand that I may be denied reimbursement for submitted vision care services for which I am not eligible. I hereby authorize any insurance company organization employer ophthalmologist optometrist and optician to release any information with respect to this claim* I certify that the information furnished by me in support of this claim is true and correct. Signature of Member/Guardian/Patient not a minor Date To Fax 866-293-7373 To Email oonclaims eyewearspecialoffers. Registered mark of WellPoint Inc* 2010 WellPoint Inc* 5/14/02 Fraud Warning Statements Arizona For your protection Arizona law requires the following statement to appear on this form* Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. Alaska A person who knowingly and with intent to injure defraud or deceive an insurance company files a claim containing false incomplete or misleading information may be prosecuted under state law. Arkansas Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison* California For your protection California law requires the following to appear on this form Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty Colorado It is unlawful to knowingly provide false incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company.