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 Certication 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 Qualied
Medical Expenses
Total Amount for all expenses:
0520
IN01200985A200507
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signature
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We are required by the Privacy Act of 1974 (5 U.S.C. 552a) to tell you what personal information we collect and how it will be used: Authorities – This information is requested pursuant
to 42 U.S.C. 4955, Support services; 42 U.S.C. 12618, Authorized benefits for Corps members; and 45 CFR § 2556.320 - What benefits may a VISTA receive during VISTA service?
Purposes It is requested to manage and evaluate the health benefits programs offered to VISTA, NCCC, and FEMA Corps Members. Routine Uses Routine uses of this
information may include disclosure to (1) health care providers and insurance companies to provide care and coordinate payment, (2) contractors to assist with providing the health
care benefit, and (3) federal, state, or local agencies pursuant to lawfully authorized requests. Effects of Nondisclosure This request is voluntary, but not providing the
information will likely affect your ability to receive your health care benefits.
*Notice on Electronic Communication and Privacy: Please submit these documents via secure means, such as encrypted email or by fax. If you choose to send the information
via unsecure email, you are solely responsible for any subsequent data breach or data loss caused by your decision. To protect your private information, we recommend you consider
using any secure or confidential/encrypted email sending options with your email service provider. You may also consider password protecting your documents and sending the
password in a separate email.
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