Fillable Opticare-of-utah-out-of-network-reimbursement-form-fillout Out of Network Reimbursement Form

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Opticare-of-utah-out-of-network-reimbursement-form-fillout Out of Network Reimbursement Form

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Insured Member Identification Number
Insured Member's Full Name
Insured Daytime Phone Number
Insured Address
Patient Name
Date of Service
Place of Service - Provider Name
Provider Phone Number
Provider Address
Itemized Price(s) Paid Examination
Dilation
Contact Fitting
Lenses
Scratch Coating
UV Coating
Coatings and Extras
Frame
Contact Lenses
Please submit completed form & itemized receipt to:
Opticare of Utah
1901 West Parkway Blvd
Salt Lake City, UT 84119
Fax (801) 954-0054
Toll Free Fax (888) 547-4227
service@opticareofutah.com
Questions or Comments : (800) 363-0950
www.opticareofutah.com
Policy and Procedures
Opticare of Utah will process your claim within 30 days from the date received. All information requested
is required to process your claim completely. If information is missing, the claim will not be processed completely
and may add time to the receipt of payment. Opticare of Utah will mail your check to the insured's mailing address
listed on file. If the address may have changed recently, please contact the insured's Human Resource department to
have them submit the address change to Opticare of Utah for updating.
Out of Network Provider must be a
licensed Optician, Optometrist, or Ophthalmologist to qualify - No website/online
purchases are covered. Full Allowance qualification is based on retail pricing. Please see Plan Outline.
OOU.OON.REQ
Opticare of Utah Out of Network Reimbursement Request
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Opticare-of-utah-out-of-network-reimbursement-form-fillout Out of Network Reimbursement Form

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Completed 13 February 2020

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