Follow the steps to complete the reimbursement questionnaire online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the date at the top of the form, ensuring it corresponds with your submission date.
3. Enter the patient name and date of birth, ensuring to fill out the MHBP ID number accurately.
4. Indicate the patient's relationship to the enrollee. If you are filling this out for someone else, provide your name and your relation to the enrollee.
5. Provide your contact information, including your phone number, fax number (if available), and email address.
6. Select the preferred method for contact and provide the best time to reach you, either in the AM or PM.
7. Indicate the cause of the illness or injury by selecting the appropriate option. If the selection is 'Other,' provide a brief description.
8. Specify the location where the injury or illness occurred, whether it was at work, home, or another location, and enter the date of the incident.
9. Describe the cause of the injury or illness in detail. Attach copies of any accident reports as required.
10. If you have hired an attorney, enter their name, law firm, contact information, and address.
11. Provide details regarding the insurance policy, including the insurer’s name, policyholder name, contact information for the insurance adjuster, and the insurance claim number.
12. Select the type of insurance coverage relevant to your claim.
13. Review the information you have entered to ensure accuracy. Once everything is complete, sign and date the form.
14. Save your changes, and choose to download, print, or share the completed form as required.

Complete the Mail Handlers Benefit Plan Reimbursement Questionnaire online today to ensure a smooth reimbursement process.