Forms available online Washington State Health Care Authority 2026

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4.1 out of 5

32 votes

The document is a Vision Claim Form used to request reimbursement for services from non-network providers or for purchasing prescription eyewear. It outlines the necessary steps for completing the form, including providing patient and provider information, attaching itemized bills, and submitting the claim to Regence BlueShield. The form is applicable for various Uniform Medical Plans and emphasizes the importance of filing claims within one year of service.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the EMPLOYEE/RETIREE INFORMATION section. Enter your UMP Identification Number, ensuring to include any alpha characters.
Next, complete the PATIENT INFORMATION section with the patient's last name, first name, middle initial, date of birth, sex, and relationship to the subscriber. Include a daytime phone number for contact.
In the EXAMINING PHYSICIAN OR OPTOMETRIST INFORMATION section, provide details about the services rendered including the date of service and physician's information. Ensure you include diagnosis and procedure codes.
For SUPPLIER INFORMATION, either have your provider complete this section or attach a copy of the prescription. Fill in details regarding lenses or glasses ordered.
Finally, sign in the EMPLOYEE/RETIREE RELEASE INFORMATION section to authorize release of medical information necessary for processing your claim.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (111 Votes)
2016	4.1 Satisfied (32 Votes)

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How is Medicaid funded in Washington state?

The Medicaid program is jointly funded by the federal and state governments, and at least 50 percent of each states Medicaid funding is matched by the federal government, although the exact percentage varies by state. Medicaid is the largest source of federal funding that states receive.

Is Washington Apple Health the same as Medicaid?

In Washington State, we call the Medicaid program Apple Health. Apple Health provides health care coverage to nearly 2 million residentsadults and children.

What kind of insurance is Washington Apple Health?

Washington Apple Health (Medicaid) is free or low-cost health care coverage for individuals who meet the eligibility requirements. Apple Health covers physical and behavioral health services, including mental health and substance use disorder treatment services.

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What does HCA stand for in Washington state?

Health Care Authority (HCA) means the Washington State Health Care Authority, any division, section, office, unit or other entity of HCA, or any of the officers or other officials lawfully representing HCA.

What is covered by Apple Health Washington?

You or your family may qualify for free or low-cost Apple Health coverage. Coverage includes primary care, emergency visits, maternity services, pediatric care, dental services, vision care, prescription medications and more.

Does Washington state have managed Medicaid?

Washington has been operating physical health managed care since 1987. Currently, physical health managed care, called Apple Health, is operating under Section 1932(a) authority through five statewide managed care organizations.

Who administers Medicaid in Washington state?

Washington State Health Care Authority.

How does Washington Medicaid work?

Medicaid does not pay money to you. It sends payments directly to your health care providers. Medicaid can pay for medical services in your own home or if you live in a residential care facility that takes Medicaid residents. Learn more about how to apply for Medicaid.

Forms available online Washington State Health Care Authority 2026

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