Fillable Online hca wa MEDICAL CLAIM FORM Uniform ... 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the EMPLOYEE/RETIREE INFORMATION section. Enter your UMP Identification Number, last name, first name, and other required details.
3. Next, complete the PATIENT INFORMATION section. Provide the patient's last name, first name, date of birth, sex, and relationship to the subscriber.
4. In the EXAMINING PHYSICIAN OR OPTOMETRIST INFORMATION section, input the date of service and services rendered. Ensure to include any diagnosis and procedure codes as well as charges.
5. Fill out the SUPPLIER INFORMATION section completely or attach a copy of the prescription. Include details about lenses or glasses ordered.
6. Finally, sign and date the EMPLOYEE/RETIREE RELEASE INFORMATION section before submitting your claim form.

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