A medical reimbursement form is filled out by providing personal information about the insured patient, which includes patient name, address and member identification number. Claim forms often require other personal information such as patient date of birth, whether the patient is a subscribed health plan member, and type of insurance held by the patient, states Group Health. Specific details about the medical provider and medical services performed must be included as well.Continue Reading
A standard medical reimbursement form includes treatment dates, a brief description of medical treatment and corresponding medical procedure codes, notes United Healthcare. A diagnosis code is also a common feature of claim forms. Health plan members must then provide medical practitioner details, which is usually the doctor or health professional who attended to the patient. The practitioner's billing address and tax identification number are important details that must be submitted.
Claim forms have a section for including the amount of money paid towards the itemized list of medical procedures. Members must submit proof of payment in the form of a credit card receipt, cancelled check or document from the medical practitioner indicating payment, according to Group Health. Claims submitted for reimbursement of prescribed medication must include drug name, prescription strength, quantity of medication and cost of the prescription.Learn more about Health Insurance