Your claim and images are being uploaded. Please do not refresh your browser.
Complete the sections below, attach electronic copies of your receipts and click submit for your claim to be processed.
List all prescriptions purchased. Please attach receipts for every expense. Attach your physician's written recommendation and diagnosis where applicable.
Note: All fields are required except for Dispensing Fee
Note: Touch title area to scroll.
Name of Patient
Birth Date
Relation to Member
Date of Expense
DIN
Dispensing Amount Fee
Amount Charged (Drug Cost)
Total Charged
List all services and/or items purchased. Please attach receipts for every expense. Attach your physician's written recommendation and diagnosis where applicable.
Note: All fields are required
Type of Expense
Subtype
Complete all sections in the form below for each dental procedure. Attach a copy of the dental claim statement provided by your dental office.
Note: All fields are required except for Lab Charge, Tooth Surface and Tooth Code (provide these if available)
Date of Service
Procedure Code(5 digit)
Tooth Code
Tooth Surface
Lab Charge(If applicable)
Dentist's Fee
All of the remaining portion of the claim to be paid
Or
A specific amount $