Get Vaccine And Administration (injection) Claim Form - Mvp Health Care

This guide provides clear, step-by-step instructions for completing the Vaccine And Administration (Injection) Claim Form for MVP Health Care online. By following these instructions, users can ensure their claims are submitted accurately and efficiently.

Follow the steps to complete your claim form successfully.

1. Press the ‘Get Form’ button to acquire the Vaccine And Administration (Injection) Claim Form and open it in your editor.
2. Fill in your member or subscriber information as indicated in section 1. Ensure to include your MVP ID, group number, member ID, full name, address, city, state, zip code, and date of birth.
3. If your vaccine was obtained at a pharmacy, complete section 2 with the pharmacy’s name, address, city, state, zip code, phone number, and national provider ID number.
4. If your vaccine was received at a physician's office or department of health, fill out section 3 with the prescribing physician’s name, address, city, state, zip code, and national provider ID number.
5. Proceed to section 4 and check the applicable boxes that represent what you are submitting for reimbursement: the vaccine, the administration (injection), or both.
6. In section 5, carefully read the acknowledgment, then provide your signature and date to certify the information is accurate.
7. In section 6, select the box that corresponds to how you obtained your vaccine, ensuring you check box E if it was through your physician's office or local Department of Health.
8. For section 7, check the relevant vaccine from the list provided and enter all necessary details including vaccine name, NDC number, quantity, vaccine charge, and administration fee. If your vaccine isn’t listed, provide the necessary details in the blank space.

Complete your Vaccine And Administration (Injection) Claim Form online today for a faster reimbursement process.