Reimbursement Form Tufts Health Plan Medicare Preferred (Page 2 of 2) in pdf

Reimbursement Form Tufts Health Plan Medicare Preferred Page 2

MeMber reiMburseMent ForM

signature is required

I attest that the information is accurate and complete.

Member’s Signature: ___________________________________________ Date: _____________________

tufts Health Plan

senior Care options

Member reimbursement

P.o. box 9183

Watertown, MA 02471-9183

NOTE: For Wellness Allowance reimbursement, please use the Wellness Allowance Benefit form.

This document may be available upon request in an alternate format such as Braille, larger print, or audio.

Tufts Health Plan is an HMO-SNP plan with a Medicare contract. Enrollment in Tufts Health Plan depends

on contract renewal. Tufts Health Plan Senior Care Options is a voluntary MassHealth (Medicaid) benefit in

association with the Executive Office of Health and Human Services (EOHHS) and the Centers for Medicare

& Medicaid Services (CMS).

This information is available for free in other languages. Please call our Customer Relations number at

1-855-670-5934, (TTY 1-855-670-5936), Monday - Friday 8 a.m. - 8 p.m. (from Oct. 1 - Feb. 14 representatives

are available 7 days a week, 8:00 a.m. - 8:00 p.m.).

Esta información está disponible de forma gratuita en otros idiomas. Comuníquese con nuestro departamento

de atención al cliente al número 1-855-670-5934 para obtener información adicional. (Los usuarios de TTY

deben llamar al 1-855-670-5936). El horario es de lunes a viernes, de 8 am a 8 pm (del 1 de octubre al 14 de

febrero, los representantes están disponibles los 7 días a la semana, de 8 am a 8 pm).

Reimbursement Form Tufts Health Plan Medicare Preferred Page 2