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Get Flu Shot Paperwork

Coventry Health Care of Missouri Inc. Coventry Health Care Reimbursement Form for Flu Shot If you obtain your flu shot from a provider who is not participating with Coventry Health Care of Missouri Inc. Coventry Health Care please note that you will be reimbursed up to the Medicare allowable for the flu shot. If the provider from whom you received your flu shot charges more than this you will be responsible for the balance. Please complete this reimbursement form attach your paid receipt and send them to the address listed below. Today s Date Name Address City State Zip Member Number Date of Birth Primary Care Physician Date of Flu Shot Place Received This form is to be used for flu shot reimbursement only. Please ask your participating physician if a pneumonia shot is recommended for you. Please return this form along with copy of paid receipt to P. If the provider from whom you received your flu shot charges more than this you will be responsible for the balance. Please complete this reimbursement form attach your paid receipt and send them to the address listed below. Please complete this reimbursement form attach your paid receipt and send them to the address listed below. Today s Date Name Address City State Zip Member Number Date of Birth Primary Care Physician Date of Flu Shot Place Received This form is to be used for flu shot reimbursement only. Today s Date Name Address City State Zip Member Number Date of Birth Primary Care Physician Date of Flu Shot Place Received This form is to be used for flu shot reimbursement only. Please ask your participating physician if a pneumonia shot is recommended for you. Please return this form along with copy of paid receipt to P. If the provider from whom you received your flu shot charges more than this you will be responsible for the balance. Please complete this reimbursement form attach your paid receipt and send them to the address listed below. Today s Date Name Address City State Zip Member Number Date of Birth Primary Care Physician Date of Flu Shot Place Received This form is to be used for flu shot reimbursement only. Please complete this reimbursement form attach your paid receipt and send them to the address listed below. Today s Date Name Address City State Zip Member Number Date of Birth Primary Care Physician Date of Flu Shot Place Received This form is to be used for flu shot reimbursement only. Please ask your participating physician if a pneumonia shot is recommended for you. Please return this form along with copy of paid receipt to P.

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  • medicare
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