Medical Reimbursement Claim Form

Medical Reimbursement Claim Form
Date
MonthDayYear
Date
Membership ID
Is the Patient the Principal or Dependent of Member?
Patient is the Principal MemberPatient is Dependent of Member
Name of Patient
First NameLast Name
Date of Birth
MonthDayYear
Date
Age
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Civil Status
SingleMarriedWidowedDivorcedSeparated
Gender
MaleFemaleOther
Phone Number
Please enter a valid phone number.
Email
example@example.com
Occupation
Clinic/Hospital Information
Hospital Name
Phone Number
Please enter a valid phone number.
Name of Physician
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Treatment Information
Service Rendered
Behavioral healthPeriodic Medical Check-upInpatient hospital careInpatient surgeryOutpatient surgeryEmergency room visitLab or x-ray servicesCovered prescription drugsMedical suppliesOther
Describe the Treatment Made
Procedures*
Attach receipts and other documents here
Cancelof
I hereby declare, under the penalty of perjury of the laws of the United States that the information I provided above is true and correct to the best of my knowledge.
Name
First NameLast Name
Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty:

Clinic/Hospital Information