Reimbursement Form Tufts Health Plan Medicare Preferred printable pdf download

MeMber reiMburseMent ForM

required information

Last Name: __________________________ First Name: ________________________ Middle Initial: ____

Member ID #: ______________________________________ Date of Birth: ____ / ___ / ___________

( M M / D D / Y Y Y Y )

Name of Provider of Service: __________________________ Date(s) of Service: ____________________

Phone Number and Address of Provider (if known): ____________________________________________

in what setting did you receive treatment? (e.g. office, ER, hospital, clinic, etc.) _____________________

use reverse side or another sheet of paper to include any additional information if necessary.

Amount of reimbursement you are requesting: $ ______________________________________________

if services were performed outside of the usA:

In what country were services performed? ________________________________________________

In what language was the bill/receipt written? _____________________________________________

In what currency was the bill paid? ______________________________________________________

Describe the items or services that you were seen for.

(e.g. asthma, lab work, ER visit, flu shot, eyewear, durable medical equipment

, etc.)

_______________________________________________________________________________________

Please include Proof of Payment AnD itemized receipt

Check which of the following acceptable proof of payment you are attaching to this form.

 A copy of the front and back of the cancelled check written to the provider or the bank encoded front

of the check written to the provider.

 A credit card statement or receipt with itemized bill and authorization, if applicable.

 A statement from the provider, on the provider’s letterhead with authorized signature,

indicating payment was made.

Tufts Health Plan Senior Care Options requires prior authorization for certain drugs, devices, and

equipment as a condition of payment. Refer to your Evidence of Coverage booklet for your plan’s

guidelines.

Prescription required for Durable Medical Equipment purchase.

A receipt for purchased items, with the provider’s name and address preprinted on the receipt,

with items listed and the amount paid.

H2256_S_2016_25

Reimbursement Form Tufts Health Plan Medicare Preferred