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How to use or fill out Forms available online Washington State Health Care Authority

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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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