Umr Medical Claim Form

• Umr Medical Claims Address
• Umr Medical Provider Login

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Umr Medical Claim Form

HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08 05 NUCC Instruction Manual available at www nucc OMB No 1215 0055 Expires 10 31 2009 BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS SEE SEPARATE INSTRUCTIONS ISSUED BY CLAIM SUBMISSION FORM Please complete this form and send it, along with the detailed bill from your health care provider, to the address or fax number provided below. PLEASE PRINT. GROUP INFORMATION Group/Employer Name: Group # (printed on employee ID card): EMPLOYEE INFORMATION Employee Full Name: Employee Address: Street.

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Umr Medical Claim FormYou may submit your claim to UMR by one of the following methods: FAX: 855-405-2189 Mail: UMR PO Box 8033 Wausau WI 54402-8033 Email a pdf of your claim and documents to: [email protected] Facility Name: Breast Pump Durable medical equipment Other (complete below) Use this form to file a claim for any eligible medical expense when your physician or other provider does not file a claim Please print clearly with black ink completing all required fields Attach your itemized statement or fully legible copy of the bill to the back of this form Keep a copy for your records

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