Get Reimbursement Claim Form 2015 - Ventura County Health Care Plan - Vchealthcareplan

Filling out the Reimbursement Claim Form is an essential step for users seeking reimbursement for medical services under the Ventura County Health Care Plan. This guide provides clear instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete your reimbursement claim form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Verify and complete your employee or subscriber information, including your policy number, home phone, and work phone.
3. Fill out the patient information section by providing the patient's name, street address, city, state, and zip code.
4. Select the type of service performed by marking the appropriate option, such as annual vision exam or chiropractic/acupuncture.
5. Complete the provider information section by entering the name, address, and phone number of the service provider.
6. Input the date(s) of service and the total cost of the service provided.
7. If applicable, indicate the number of visits for the services received.
8. Sign the claim form on the employee signature line and enter the date of signing.
9. Attach the bill from the provider and your payment receipt to this form.
10. Mail the completed form, along with the attachments, to Ventura County Health Care Plan, Care Reimbursements, 2220 E. Gonzales Road, Suite 210-B, Oxnard, California 93036.

Complete your Reimbursement Claim Form online to ensure a swift reimbursement process.