Medicare Claim Reimbursement Form printable pdf download

Medicare Claim Reimbursement Form

Refer to your

member ID card

for claim mailing

address

Before you get started:

Fill out this form if you’re asking for a medical, dental, hearing aid or vision reimbursement and you were billed

by a provider who did not bill us directly. Don’t use this form for a prescription drug reimbursement. Please call

the number on your member ID card for help with prescription drug reimbursements.

To get the reimbursement, you should:

— Simply complete this claim form.

— Attach your paid receipt. Be sure to include your member ID number on the receipt.

— Attach your itemized bill from the provider.

Your name

Your member ID number

Address

Date of birth (MM/DD/YYYY)

City, state, ZIP code

Daytime phone number

(

)

Select reimbursement type:



Dental allowance

Flu/pneumococcal vaccine

reimbursement



Hearing aid reimbursement

Other pharmacy (Part B)

reimbursement



Lens reimbursement

Foreign claims reimbursement



Post-cataract eyewear

Other — please specify below

reimbursement

_______________________

Procedures, medical services, supplies provided:

Date of Service

Description of Service (include procedure code if available)

Charges

Send this completed form, a copy of the receipt and provider bill to the address on your member ID card.

Or, you can fax your request, plus copies of the receipt and provider bill, to 1-866-474-4040.

Medicare Claim Reimbursement Form