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THE FOLLOWING INFORMATION MUST BE ON YOUR RECEIPT OR ON YOUR PROVIDER INVOICE AND SUBMITTED WITH THIS CLAIM FORM IN ORDER TO PROCESS YOUR CLAIM PLEASE CHECK EACH BOX Cash register receipts or cancelled checks are not an acceptable claim. Diagnosis Code Provider Tax Identification Number TIN Billed Charges and Amount Paid Date of Service CPT procedure Code Provider Name. For prescription claims please provide a copy of the drug receipt outlining name of the pharmacy drug Rx number and date purchased. Issue Payment to Provider or Employee Employee s Signature 855-444-2896 Date Mail the claims to UMR PO Box 30541 Salt Lake City UT 84130-0541 Email a. EZ Claim Form Medical/Vision Name of Employer Group Patient s Name Date of Birth // Last Name First Middle Initial No Yes Is claim related to an accident If yes provide details including date description and location of accident Is patient covered by another group plan If yes type of other coverage Medical Dental Vision Carrier Group Number Employee Name ID Number Name of Employer Please attach your prescription receipts and physician s statement. THE FOLLOWING INFORMATION MUST BE ON YOUR RECEIPT OR ON YOUR PROVIDER INVOICE AND SUBMITTED WITH THIS CLAIM FORM IN ORDER TO PROCESS YOUR CLAIM PLEASE CHECK EACH BOX Cash register receipts or cancelled checks are not an acceptable claim* Diagnosis Code Provider Tax Identification Number TIN Billed Charges and Amount Paid Date of Service CPT procedure Code Provider Name. For prescription claims please provide a copy of the drug receipt outlining name of the pharmacy drug Rx number and date purchased* Issue Payment to Provider or Employee Employee s Signature 855-444-2896 Date Mail the claims to UMR PO Box 30541 Salt Lake City UT 84130-0541 Email a. EZ Claim Form Medical/Vision Name of Employer Group Patient s Name Date of Birth // Last Name First Middle Initial No Yes Is claim related to an accident If yes provide details including date description and location of accident Is patient covered by another group plan If yes type of other coverage Medical Dental Vision Carrier Group Number Employee Name ID Number Name of Employer Please attach your prescription receipts and physician s statement. THE FOLLOWING INFORMATION MUST BE ON YOUR RECEIPT OR ON YOUR PROVIDER INVOICE AND SUBMITTED WITH THIS CLAIM FORM IN ORDER TO PROCESS YOUR CLAIM PLEASE CHECK EACH BOX Cash register receipts or cancelled checks are not an acceptable claim* Diagnosis Code Provider Tax Identification Number TIN Billed Charges and Amount Paid Date of Service CPT procedure Code Provider Name. .