Medical

Don't want to fill out the reimbursement online? Print the form here.

An Itemized receipt is Required for any reimbursement

Policy Information

Policy Holders First Name

Policy Holders Last name

Member ID #

Mailing Address

City

State

Patient Information

Zip

Patient First Name

Patient Last name

Patients Month of Birth

Patients Day of Birth

Other Coverage Information

Does patient have other medical coverage?

If yes, name of other insurance

Policy # for other coverage

Effective Date for other coverage

Additional Information

Is treatment related to an injury?

If yes, please describe How, When and Where the accident took place.

Provider Information

If this is not applicable, please enter NA in fields below.

Provider Name/ Facility

Address

NPI

TAX ID

Phone #

Services Rendered
This information will need to be obtained from your provider, if not listed on your receipt.

If this is not applicable, please enter NA in fields below.

Date of Service (One Per Reimbursement)

Dx Codes (separate with a comma)

CPT Codes (separate with a comma)

Amount Paid

Form of Payment

Policy Holder EmailPolicy Holder Signature

Phone #Date

Upload Itemized Receipt

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Your Reimbursement form has been successfully submitted. You will receive confirmation once this claim has been processed. Please allow 14 business days before checking the status of this reimbursement.
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If you submitted wrong information, or have any questions, please reach out to Info@samerahealth.com.

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What kind of claim are you wanting to get reimbursed for?

Select the form:

Medical

Policy Information

Patient Information

Other Coverage Information

Additional Information

Provider Information

If this is not applicable, please enter NA in fields below.

Services Rendered
This information will need to be obtained from your provider, if not listed on your receipt.

If this is not applicable, please enter NA in fields below.

What kind of claim are you wanting to get reimbursed for?

Select the form:

Medical

Policy Information

Patient Information

Other Coverage Information

Additional Information

Provider Information

If this is not applicable, please enter NA in fields below.

Services Rendered This information will need to be obtained from your provider, if not listed on your receipt.

If this is not applicable, please enter NA in fields below.

Services Rendered
This information will need to be obtained from your provider, if not listed on your receipt.