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How to use or fill out UPMC Out of Network Claim Form with DocHub
- Click ‘Get Form’ to open the UPMC Out of Network Claim Form in our editor.
- Begin by filling out the Member Information section. Enter your name, date of birth, and UPMC for Life ID number. If you have a new address, make sure to check the corresponding box and provide your street address, city, state, and zip code.
- Next, move to the Provider Information section. Input the provider's name, street address, city, state, zip code, and phone number.
- Once all fields are completed, review your entries for accuracy. Then print the form if necessary.
- Sign and date the claim form at the designated area.
- Attach a 'super bill' or itemized receipt that details the services received and mail it to OptiCare Managed Vision at the provided address.
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