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

M.I.

Date of birth

Address

City

State

ZIP code

Amount paid for flu shot

Location where you received the flu shot

Date you received the flu shot

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 ¡ª independent licensees of the Blue Cross and Blue Shield Association.

1181123 (10/20)

Language Assistance Services

Tagalog: PAUNAWA: Kung nagsasalita ka ng

Tagalog, magagamit mo ang mga serbisyo na tulong

sa wika nang walang bayad. Tumawag sa

1-800-275-2583.

Spanish: ATENCI?N: Si habla espa?ol, cuenta con

servicios de asistencia en idiomas disponibles

de forma gratuita para usted. Llame al

1-800-275-2583 (TTY: 711).

French: ATTENTION: Si vous parlez fran?ais, des

Language Assistance Services

services d'aide linguistique-vous

sont

propos¨¦s Kung nagsasalita ka

Tagalog:

PAUNAWA:

gratuitement. Appelez le 1-800-275-2583.

Chinese: ×¢Ò⣺Èç¹ûÄú½²ÖÐÎÄ£¬Äú¿ÉÒԵõ½Ãâ·ÑµÄÓïÑÔ

Tagalog, magagamit mo ang mga serbisyo

Spanish: ATENCI?N: Si habla espa?ol, cuenta con

ЭÖú·þÎñ¡£Öµç 1-800-275-2583¡£

sa wika nang walang bayad. Tumawag sa

servicios de asistencia en idiomas disponibles

Pennsylvania Dutch: BASS UFF: Wann du

1-800-275-2583.

de forma

gratuita??,

para ??

usted. Llame alPennsylvania Deitsch schwetzscht, kannscht du Hilf

Korean: ????: ????

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1-800-275-2583 (TTY: 711).

griege in dei eegni Schprooch

unniATTENTION:

as es dich ennich

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Si vous parlez fran?

?? ???? ??? ???? ? ????.

eppes koschte zellt. Ruf die

Nummer

1-800-275-2583.

services

d'aide

linguistique-vous sont prop

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gratuitement. Appelez le 1-800-275-2583.

Chinese: ×¢Ò⣺Èç¹ûÄú½²ÖÐÎÄ£¬Äú¿ÉÒԵõ½Ãâ·ÑµÄÓïÑÔ

1-800-275-2583¡£ Hindi: ???? ?? : ??? ?? ????? ????? ?? ?? ???? ???

Portuguese: ATEN??O:ЭÖú·þÎñ¡£Öµç

se voc¨º fala portugu¨ºs,

Pennsylvania Dutch: BASS UFF: Wann d

encontram-se dispon¨ªveis servi?os gratuitos de

???? ?? ???? ?????? ??????

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??? ??? schwetzscht, kannsc

Pennsylvania

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assist¨ºncia ao idioma. Ligue

para 1-800-275-2583.

griege in dei eegni Schprooch unni as es d

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Hindi: ????

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Sie kostenlos sprachliche

Unterst¨¹tzung

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???? ????? ATEN??O:

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se voc¨º falak?nnen

portugu¨ºs,

anfordern.

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encontram-se

dispon¨ªveis

servi?os

gratuitos

de

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assist¨ºncia ao idioma. Ligue para 1-800-275-2583.

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Japanese: ‚俼£ºÄ¸¹úÕZ¤¬ÈÕ±¾ÕZ¤Î·½¤Ï¡¢ÑÔÕZ¥¢¥·¥¹

Vietnamese: L?U ?: N?u b?n n¨®i ti?ng Vi?t, ch¨²ng t?i

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? ????:

??, ?? ??:??? ?

s? cung c?p d?ch v? h? tr?

ng?n ng?

mi?n ??

ph¨ª???

cho??

German: ACHTUNG: Wenn Sie Deutsch s

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b?n. H?y g?i 1-800-275-2583.

k?nnen Sie kostenlos sprachliche Unterst¨¹

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anfordern. W?hlen Sie 1-800-275-2583.

Persian (Farsi):

Russian: §£§¯§ª§®§¡§¯§ª§¦: §¦§ã§Ý§Ú

§Ó§í §Ô§à§Ó§à§â§Ú§ä§Ö???

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.?????? ?? ?????

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1-800-275-2583

§á§Ö§â§Ö§Ó§à§Õ§Ñ. §´§Ö§Ý.: 1-800-275-2583.

Vietnamese: L?U ?: N?u b?n n¨®i ti?ng Vi?t, ch¨²ng t?i

¥¿¥ó¥¹¥µ©`¥Ó¥¹£¨ŸoÁÏ£©¤ò¤´ÀûÓ䤤¿¤À¤±

.????? ???????

s? cung c?p d?ch v? h? tr? ng?n ng? mi?n ph¨ª cho

1-800-275-2583¤Ø¤ªëŠÔ’¤¯¤À¤µ¤¤¡£

Polish UWAGA: Je?eli m¨®wisz

po polsku,

mo?esz

b?n. H?y

g?i 1-800-275-2583.

skorzysta? z bezp?atnej pomocy j?zykowej. Zadzwo¨½

Persian

(Farsi):

D77 saad

bee y1n7[ti¡¯go

Navajo: D77 baa ak0 n7n7zin:

pod numer 1-800-275-2583.

Russian: §£§¯§ª§®§¡§¯§ª§¦: §¦§ã§Ý§Ú §Ó§í §Ô§à§Ó§à§â§Ú§ä§Ö §á§à-§â§å§ã§ã§Ü§Ú,

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saad

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H0d77lnih

koj8¡¯

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Italian: ATTENZIONE: Se§á§Ö§â§Ö§Ó§à§Õ§Ñ.

lei parla italiano,

sono

§´§Ö§Ý.: 1-800-275-2583.

disponibili servizi di assistenza linguistica gratuiti.

Chiamare il numero 1-800-275-2583.

Polish UWAGA: Je?eli m¨®wisz po polsku,

Urdu:mo?esz

skorzysta? z bezp?atnej pomocy j?zykowej. Zadzwo¨½

? ?? ?? ?? ??????????? ????Navajo:

????? ?????D77

????baa

? ????ak0

:?????????

??????D77 saad bee y

n7n7zin:

Arabic:

pod numer 1-800-275-2583.

??????? ???? ??? ?????

?????? ??????

???? ????

Din¨¦ Bizaad,

saad ??????

bee 1k1¡¯1n7da¡¯1wo¡¯d66¡¯,

? ??? ????? ???????? ?????????? ??? ??? ????? ????? ????????:????????

.

1-800-275-2583

H0d77lnih

koj8¡¯

1-800-275-2583.

Italian:

ATTENZIONE:

Se???????

lei parla italiano, sono

.1-800-275-2583

??????

? ?????.??? ????????

disponibili servizi di assistenza linguistica gratuiti.

: ??????????????????

Chiamare

il numero

French Creole: ATANSYON:

Si w pale

Krey¨°l1-800-275-2583. Mon-Khmer, CambodianUrdu:

Ayisyen, gen s¨¨vis ¨¨d pou lang ki disponib gratis pou

??? ????

? ?? ?????????? ???????

????????????????????-???

? ??????

??? ???? ?? ???? ?????

ou. Rele 1-800-275-2583.Arabic:

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.?????? ?? ????????

???????? ??????????? 1-800-275-2583?

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.

Y0041_HM_17_47643 Accepted 10/14/2016

Y0041_HM_17_47643 Accepted 10/14/2016

Mon-Khmer, Cambodian: ????????????

????????????????????-???? ???

???????????????????????????????

???????? ??????????? 1-800-275-2583?

Taglines as of 10/14/2016

Taglines as of 10/14/2016

Discrimination is Against the Law

If you need these services, contact our Civil Rights

Coordinator. If you believe that This Plan has failed

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

Rights Coordinator. You can file a grievance in the

following ways: In personTagalog:

or by mail:PAUNAWA:

ATTN: CivilKung nagsasalita ka

Tagalog,

magagamit

Rights

Coordinator,

1

9

0

1

M

a

r

k

e

t

S

t r e e t , mo ang mga serbisyo

Spanish: ATENCI?N: Si habla espa?ol, cuenta con

This Plan provides:

sa

wika

nang

walang

bayad. Tumawag sa

P

h

i

l

a

d

e

l

p

h

i

a

,

P

A

1

9

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3

,

By

phone:

1-888-377servicios de asistencia en idiomas disponibles

? Free aids and services to people with disabilities

1-800-275-2583.

3933

(TTY:

711)

By

fax:

215-761-0245,

By

email:

de forma gratuita para usted. Llame al

to communicate effectively with us, such as:

civilrightscoordinator@. If you need

1-800-275-2583 (TTY: 711).

French: ATTENTION: Si vous parlez fran?

qualified sign language interpreters, and written

help filing a grievance, our Civil Rights Coordinator is

services d'aide linguistique-vous sont prop

information in other formats (large print, audio,

available to help you.

gratuitement. Appelez le 1-800-275-2583.

Chinese:

accessible electronic

formats,×¢Ò⣺Èç¹ûÄú½²ÖÐÎÄ£¬Äú¿ÉÒԵõ½Ãâ·ÑµÄÓïÑÔ

other formats).

ЭÖú·þÎñ¡£Öµç

1-800-275-2583¡£ You can also file a civil rights complaint with the U.S.

? Free language services

to people whose

Pennsylvania Dutch: BASS UFF: Wann d

primary language is not English, such as:

Department of Health and Human Services, Office for

Pennsylvania Deitsch schwetzscht, kannsc

Korean:

????:written

????

??

qualified interpreters

and information

in ?????

Civil??,

Rights

electronically through the Office for Civil

griege in dei eegni Schprooch unni as es d

other languages. ?? ???? ??? ???? ? ????.

Rights Complaint Portal, available at

eppes koschte zellt. Ruf die Nummer 1-800

1-800-275-2583 ??? ??????. or by mail

or phone at: U.S. Department of Health and Human

Hindi:Avenue

???? ??SW.,

: ???Room

?? ????? ????? ?? ??

Portuguese: ATEN??O: se voc¨º falaServices,

portugu¨ºs,200 Independence

509F, HHH

DC

20201,

1-800encontram-se dispon¨ªveis servi?os gratuitos

de Building, Washington,

???? ?? ???? ?????? ?????? ????? ??? ???

368-1019, 800-537-7697 (TDD). Complaint forms are

assist¨ºncia ao idioma. Ligue para 1-800-275-2583.

1-800-275-2583?

available at

.

? ???? ?????

Gujarati: ? ????: ?? ??? ??

??, ?? ??:??? ?

German: ACHTUNG: Wenn Sie Deutsch s

k?nnen Sie kostenlos sprachliche Unterst¨¹

???? ???? ????? ????? ???? ????? ?? .

anfordern. W?hlen Sie 1-800-275-2583.

1-800-275-2583 ??? ???.

This Plan complies with applicable Federal civil rights

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

because of race, color, national origin, age, disability,

Language Assistance Services

or sex.

Vietnamese: L?U ?: N?u b?n n¨®i ti?ng Vi?t, ch¨²ng t?i

s? cung c?p d?ch v? h? tr? ng?n ng? mi?n ph¨ª cho

b?n. H?y g?i 1-800-275-2583.

Russian: §£§¯§ª§®§¡§¯§ª§¦: §¦§ã§Ý§Ú §Ó§í §Ô§à§Ó§à§â§Ú§ä§Ö §á§à-§â§å§ã§ã§Ü§Ú,

§ä§à §Þ§à§Ø§Ö§ä§Ö §Ò§Ö§ã§á§Ý§Ñ§ä§ß§à §Ó§à§ã§á§à§Ý§î§Ù§à§Ó§Ñ§ä§î§ã§ñ §å§ã§Ý§å§Ô§Ñ§Þ§Ú

§á§Ö§â§Ö§Ó§à§Õ§Ñ. §´§Ö§Ý.: 1-800-275-2583.

Polish UWAGA: Je?eli m¨®wisz po polsku, mo?esz

skorzysta? z bezp?atnej pomocy j?zykowej. Zadzwo¨½

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 ? ???? ?????.?????? ?? ????????

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.

Y0041_HM_17_47643 Accepted 10/14/2016

Japanese: ‚俼£ºÄ¸¹úÕZ¤¬ÈÕ±¾ÕZ¤Î·½¤Ï¡¢

¥¿¥ó¥¹¥µ©`¥Ó¥¹£¨ŸoÁÏ£©¤ò¤´ÀûÓ䤤¿¤À¤±

1-800-275-2583¤Ø¤ªëŠÔ’¤¯¤À¤µ¤¤¡£

Persian (Farsi):

? ????? ????? ?? ???????? ???? ?? ?????

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

Mon-Khmer, Cambodian: ????????????

????????????????????-???? ???

???????????????????????????????

Taglines as of 10/14/2016

???????? ??????????? 1-800-275-2583?

 ................
................

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