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Claims & Reimbursements
Print and complete this form for medical, dental, vision, hearing, or vaccine reimbursement.
Fill out this form if you were billed directly by a provider and would like to request reimbursement for medical care (includes dental, vision, hearing and vaccines). Don’t use this form for prescription drug reimbursement.
Medical, Dental, Vision, Hearing, or Vaccine Reimbursement Form
Medical, Dental, Vision, Hearing, or Vaccine Reimbursement Form (Spanish)
No printer? No problem. Learn what to send us for reimbursement.
Enrollment
Give another person permission to help manage your care
Let someone else talk to us about your health or coverage
- One-time only: You can give us your permission by phone. We can speak with that person during that call.
- On an ongoing basis: You may want someone to speak with us more often. If so, you’ll need to mail us an Authorization for Release of Protected Health Information (PHI) form. It lets this person access your personal health information. They can also speak with us on your behalf.
Let someone file a grievance (complaint), ask for coverage or make an appeal for you
- You can choose someone to do all of the above. This person is your appointed representative. An appointment is good for one year from the date that you and your representative sign an Appointment of Representative form.
- Fill out this form below and mail it to us. Any time your representative makes a request for you, they should send us a signed copy. You'll leave Innovation Health Medicare and go to the CMS website if you link to the form.
Prescription drugs
Member exceptions, appeals and grievances
Learn more about requesting an exception or filing a grievance or appeal:
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We have free interpreter services to answer questions you may have about our health or drug plan.
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Y0123_4006_20636_2021
Page last updated: Tue Mar 16 09:46:55 EDT 2021
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