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.