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Access forms for claims and reimbursement or filing appeals.
Prescription Drug Claim Form - Español
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 (Español)
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 (Español)
Process for Medicare coverage requests, appeals & complaints
We want to be your first stop if you have a concern about your coverage or care. Call us at the number on your member ID card.
As an Innovation Health Medicare member, you have the right to:
There are different steps to take based on the type of request you have.
Choose a topic to help us find the right process for you
You can contact the Medicare Beneficiary Ombudsman (MBO) for help with a complaint, grievance or information request.
Disclaimers
Innovation Health is a HMO, PPO plan with a Medicare contract. Enrollment in our plans depends on contract renewal.
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