Get Lamaze Reimbursement Form - Upmc Health Plan

Completing the Lamaze Reimbursement Form is an essential step to secure payment for your Lamaze or Lamaze refresher course through the UPMC Health Plan. This guide provides a detailed, user-friendly approach to ensure that you accurately fill out each section of the form online.

Follow the steps to accurately complete the form

1. Click ‘Get Form’ button to obtain the reimbursement form and open it in your preferred editor.
2. Begin by entering the subscriber's name in the designated field at the top of the form. This is the name of the individual who holds the UPMC Health Plan.
3. Next, fill in the patient’s name. This is the individual who attended the Lamaze or refresher course.
4. Enter the member ID number associated with the UPMC Health Plan. This number is critical for identifying the subscriber's account.
5. Complete the patient’s address. It is important to provide accurate information for any correspondence.
6. Add the patient’s date of birth in the specified format. This helps to verify the patient's identity.
7. Insert the diagnosis code if applicable, which pertains to the reason for the course attendance.
8. Specify the start date and completion date of the course. This information is essential for processing the reimbursement.
9. Indicate whether you participated in the Lamaze course or the Lamaze refresher by checking the appropriate box.
10. Input the total charges incurred for the course and the amount paid. This will provide a clear picture of your expenses.
11. Fill in the facility's name and address where the course was held. This is important for verification purposes.
12. Enter the facility tax ID number, which is often required for reimbursement processing.
13. The instructor must provide their signature to confirm the completion of the course. Ensure they date this signature.
14. Lastly, review the entire form to ensure all fields are completed accurately. Save the changes if applicable, and you can then download, print, or share the form as needed.

Start filling out your Lamaze Reimbursement Form online to secure your reimbursement from UPMC Health Plan.