Vision Plan Claim Form
Please complete all areas of this form and attach a copy of an itemized paid receipt. This itemized receipt should include a description of the services provided. Please keep a copy of this claim form and supporting documentation for your records. The Duke Vision Plan Claim Form should be sent to UnitedHealthcare Vision Claims Department, P.O. Box 30978, Salt Lake City, Utah 84130.
Please contact UnitedHealthcare Vision at 1-800-638-3120 for additional information about out-of-network claims.
| Form Name | Format |
|---|---|
| Duke Vision Plan Claim Form (for out-of-network providers) |
* Some Duke HR forms may require you to list your Duke Unique ID. If you do not know or are unsure of your Duke Unique ID, you can look it up here.
** Some forms available on this web site are in Adobe Portable Document Format (PDF). You will need Adobe Acrobat Reader to view and print these forms.
** Some forms available on this web site are in Adobe Portable Document Format (PDF). You will need Adobe Acrobat Reader to view and print these forms.