Instructions for ling for Allowance Plan reimbursement:
1.Please fully complete this form to receive reimbursement of any eligible
out of pocket expenses after filing with your primary healthcare plan.
2.Submit this form and EOB or Paid Invoice attachments to IMG by mail at:
IMG Claim Dept., PO Box 550, Farmington, MI 48332
or by secure e-mail* at vistacare@imglobal.com or by secure fax at (855)-851-2971.
Part I: Member Information (Please print)
Member Name (Last/First/MI): _______________________________ Date of Birth: ______________
Address: ___________________________________________________________________________
City: _________________________________ State: ____________ Zip Code: _______________
Daytime Telephone Number: ___________________________
If your address has changed, please visit your MyAmeriCorps account at my.americorps.gov/mp/login/ to update.
Allowance Plan Member ID or NSPID # (as shown on your ID card): ____________________________________
Part II: Allowance Plan reimbursement details:
Method of Reimbursement: Check ACH (Please complete and submit ACH Form)
Part III: Member Certication for Reimbursement
I hereby certify all of the following:
-The above information is correct.
-I have not previously received reimbursement for these expenses.
I hereby authorize IMG or its representatives to obtain necessary information from all physicians, hospitals, medical
service providers, pharmacists, and other insurers in order to consider this submission for reimbursement.
Member Signature: _____________________________________________ Date: ______________________
Healthcare Allowance Medical Reimbursement Form
{
{
Type of Expense
Total Paid
(Combine Expenses)
Dates of Medical Service
When combining expenses, use earliest and latest dates of
service for the group of expenses.
Total Requested Amount
Beginning Date
Ending Date
Deductible
Coinsurance
Co-Payment
Other Qualied
Medical Expenses
Total Amount for all expenses:
0520
IN01200985A200507
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