Reimbursement Form Tufts Health Plan Medicare Preferred


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
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.


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