How to fill a medical reimbursement form?


Editorial team Published on

To fill out a medical reimbursement form, follow these standard steps and include the required supporting documents:

1. Get the Right Form

  • Log in online: Many insurers (such as UnitedHealthcare, Blue Cross Blue Shield, or Blue Care Network) let you fill out and submit claims directly through your member portal.
  • Download a paper form: If mailing is required, download the specific claim form from your insurance provider (or use a general standard form like the Patient's Request for Medical Payment / CMS-1490S for Medicare). Use blue or black ink if writing by hand.

2. Fill Out Subscriber & Patient Information

  • Subscriber Details: Enter the name, home address, phone number, date of birth, and member ID number of the primary policyholder (the person who holds the insurance plan).
  • Patient Details: Provide the name, date of birth, and relationship to the subscriber for the person who received the medical care.
  • Other Insurance: Indicate if the patient has coverage under another primary or secondary health plan, Medicare, or workers' compensation, and attach any relevant Explanation of Benefits (EOB).

3. Enter Treatment & Provider Details

  • Service Dates and Places: List the exact date(s) the service or treatment occurred and the place of service (such as code 11 for an outpatient office).
  • Codes and Descriptions: Fill in the CPT/procedure codes, National Drug Codes (NDC) if for prescriptions, and ICD diagnosis codes provided by your doctor or on your superbill.
  • Provider Information: Write down the provider or facility name, address, phone number, Tax Identification Number (TIN/EIN), and National Provider Identifier (NPI). (Ask the provider's billing department for these details if you are unsure).

4. Attach Required Supporting Documents

Do not send the form alone; insurers require physical or digital proof:

  • Itemized Bill or Superbill: An official statement from the doctor or hospital listing the specific services, dates, diagnosis codes, and billed amounts.
  • Proof of Payment: A copy of a cashed/cancelled check (front and back), credit card statement, electronic payment confirmation, or paid receipt.
  • Medical Records / EOB: Clinical notes showing medical necessity (if required for out-of-network or pre-authorized care) or an Explanation of Benefits from a primary payer.

5. Sign and Submit

  • Signature: Sign and date the form. Make sure to sign the release-of-information authorization, and choose whether payment should go to you (the subscriber) rather than directly to the provider.
  • Submission: Upload the form and files through your insurer's online portal or mail the complete packet to the address listed on your member ID card or the bottom of the form. Keep a copy of everything for your records.