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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.

Instructions if you can’t print the medical reimbursement form

Instructions if you can’t print the medical reimbursement form (Spanish)

Enrollment

How to enroll in ${anCompany} Medicare plan

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.

Open and print the PHI form

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.

Appointment of Representative CMS Form

Appointment of Representative CMS Form (Spanish)

Prescription drugs