Influenza Vaccine Reimbursement Form
Please use this form to obtain reimbursement if you received a flu shot in a non-participating location. Please submit one form for each member.
Please print Member identification number
Member information
Last
First
Address
City
State
Amount paid for flu shot
Location where you received the flu shot
Date you received the flu shot
M.I.
Date of birth
ZIP code
Independence Blue Cross members with HMO, POS, and PPO plans can receive up to a $50 reimbursement by mailing this form and paid receipt to the address below.
Claims Receipt Center P.O. Box 211184 Eagan, MN 55121
Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield -- independent licensees of the Blue Cross and Blue Shield Association.
1181123 (10/20)
Language Assistance Services
Tagalog: PAUNAWA: Kung nagsasalita ka ng
Spanish: ATENCI?N: Si habla espa?ol, cuenta con servicios de asistencia en idiomas disponibles de forma gratuita para usted. Llame al
Tagalog, magagamit mo ang mga serbisyo na tulong sa wika nang walang bayad. Tumawag sa 1-800-275-2583.
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Russian: : 1-800-275-2583-., . .: 1-800-27V5ie-2tn58a3m. ese: LU ?: Nu bn
n?i
Persian (Farsi):
ting V1i-8t,0c0h-2?7n5g-2t?5i83
s cung cp dch v h tr ng?n ng min ph? cho
Polish UWAGA: Jeeli mb?wnis. zHp?oy pgolis1k-u8,0m0-o27e5s-z2583.
anfordern. W?hlen Sie 1-800-275-2583.
: Ja p.anese:
.
1-800-275-2583
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disponibili servizi di assistenza linguistica gratuiti.
Chiamare il numero Arabic:
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.1-800-275-Id2tia5sl8pia3onn:ibAilTisTeErNviZz.iIOdiNaEs:sSisetelneziapalinrlgauitisatliicaanog,rasotunitoi.
N avajo:D 77 baa a:k0n7n7zin:D 77 saad bee y Din?Bizaad,saad bee 1k1'1n7da'1wo'd66',
H0d77lnih ko.j18'-810-08-0207-52-7255-823583.
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French Creole: ATANSYON: Si w pale Krey?l Ayisyen, gen s?vis ?d pou lang ki disponib gratis pou ou. Rele 1-800-275-2583.
Mon-Khmer, Cambodian: -
Y0041_HM_17_47643 Accepted 10/14/2016
Taglines as of 10/14/2016 1-800-275-2583
Y0041_HM_17_47643 Accepted 10/14/2016
Taglines as of 10/14/2016
Discrimination is Against the Law
If you need these services, contact our Civil Rights
This Plan complies with applicable Federal civil rights
Coordinator. If you believe that This Plan has failed
laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently
to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil
because or sex.
of
race,
color,
naLtioannagluoargigeinA, asgseis,tdainscaebilSitey,rvices
Rights Coordinator. You can file a grievance in the following ways: In personToargbaylomga:ilP: AUTTNNA:WCAiv:ilKung nagsasalita ka
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Portuguese: ATEN??O: se voc? falaoSpreoprvrhtiucogenuse,?ast,2: 0U0.SIn. dDeeppeanrtdmeHeninnctedoiA:fvHeenaulethS:aWnd.,HRuomoman
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Gujarati: : .gov/ocr/ofGficeer/mfilea/nin:dAeCxH.hTtmUlN. G: Wenn Sie Deutsch s
.
k?nnen Sie kostenlos sprachliche Unterst?
1-800-275-2583 .
anfordern. W?hlen Sie 1-800-275-2583.
Vietnamese: LU ?: Nu bn n?i ting Vit, ch?ng t?i s cung cp dch v h tr ng?n ng min ph? cho bn. H?y gi 1-800-275-2583.
Japanese: 1-800-275-2583
Russian: : -, . .: 1-800-275-2583.
Persian (Farsi):
1-800-275-2583 .
Polish UWAGA: Jeeli m?wisz po polsku, moesz skorzysta z bezplatnej pomocy jzykowej. Zadzwo pod numer 1-800-275-2583. Italian: ATTENZIONE: Se lei parla italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-275-2583. Arabic:
: .1-800-275-2583 .
Navajo: D77 baa ak0 n7n7zin: D77 saad bee y Din? Bizaad, saad bee 1k1'1n7da'1wo'd66', H0d77lnih koj8' 1-800-275-2583.
Urdu:
.1-80
French Creole: ATANSYON: Si w pale Krey?l Ayisyen, gen s?vis ?d pou lang ki disponib gratis pou ou. Rele 1-800-275-2583.
Mon-Khmer, Cambodian: -
Y0041_HM_17_47643 Accepted 10/14/2016
Taglines as of 10/14/2016 1-800-275-2583
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