SECTION A. PATIENT INFORMATION
Last name First name M.I.
Does the patient have other health
insurance coverage?
□ Yes □ No
Relation to subscriber □ Self
□ Spouse or domestic partner □ Dependent
Sex
□ M □ F
Date of birth (MM/DD/YYYY)
Name of other health insurance company Group no. Employer name Policy no.
SECTION B. SUBSCRIBER INFORMATION on Bright HealthCare ID Card
Identification no. Group no.
Last name First name M.I.
Street address (please include apt. no.)
City State ZIP code
Home phone no. Work phone no. Date of birth (MM/DD/YYYY)
SECTION C. COVID19 TEST INFORMATION
COVID19 TESTINGUse this section to report any FDA-approved COVID-19 tests that you paid for out of your own pocket. Complete
this form, sign the attestation, and submit the documents listed below. Please be sure that duplicate bills are not submitted.
Was this test purchased for the personal use of the person listed as “patient” in section A? ...................................................
□ Yes □ No
Was the test purchased for employment purposes? .......................................................................................................................
□ Yes □ No
Do you expect to receive reimbursement from a source other than Bright HealthCare? .........................................................
□ Yes □ No
Please indicate the manufacturer of the COVID-19 test you purchased:
Date of purchase (mm/dd/yyyy): Where the test was purchased (for example, Amazon.com):
Price paid: Number of tests per purchase (for example, did the package contain 2 tests):
Documents to submit:
1. Proof of purchase showing price paid and date of purchase.
2. Copy of the Universal Product Code (UPC) of the covid-19 test. UPCs are barcode symbols that manufacturers use to identify their
products electronically.
I certify that, to the best of my knowledge, the information on this form is true and correct. I authorize the release of any medical information
necessary to process this claim.
Signature Name Date
X
COVID At-Home Testing: IFP Member Claim Form
Please use this form to request reimbursement for at-home COVID-19 tests you have paid for out of your own pocket after
January 14, 2022. Please use a separate claim form for each patient. Your cooperation in completing all items on the claim form
and attaching all required documentation will help expedite quick and accurate processing. If you have any questions or need
help completing this form, please call our Member Services team at 844-926-4524.
Evolent
□ SD Biosensor COVID-19 At-Home Test
□ iHealth COVID-19 Antigen Rapid Test
□ Celltrion DiaTrust COVID-19 Ag Home Test
□ ACON Laboratories Flowflex COVID-19 Antigen Home Test
□ Abbott Diagnostics BinaxNOW COVID-19 Antigen Self Test
□ Abbott Diagnostics BinaxNOW COVID-19 Ag Card 2 Home Test
□ Access Bio CareStart COVID-19 Antigen Home Test
□ Ellume COVID-19 Home Test
□ InBios International SCoV-2 Ag Detect Rapid Self-Test
□ Siemens Healthineers CLINITEST Rapid COVID-19 Antigen Self-Test
□ OraSure Technologies InteliSwab COVID-19 Rapid Test
□ Becton, Dickinson and Company BD Veritor At-Home COVID-19 Test
□ Quidel QuickVue At-Home OTC COVID-19 Test
□ Cue COVID-19 Test for Home and Over The Counter (OTC) Use
□ Detect Covid-19 Test
□ Lucira CHECK-IT COVID-19 Test Kit
Please mail this claim form, your itemized receipt, and the UPC from your test to:
Bright HealthCare
P.O. Box 1587
Portland, ME 04108
click to sign
signature
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