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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