Follow the steps to successfully complete your reimbursement form

1. Click ‘Get Form’ button to obtain the Fidelity Cancer Screening Reimbursement form and open it in your chosen editor.
2. Begin by filling in the patient’s name in the designated field. Ensure you include the full name as it appears on official documents.
3. Select the relationship to the policyholder from the options provided by marking the appropriate box (self, spouse, child). If the patient is a dependent child aged between 21-25, include the school name and submit a copy of the transcript.
4. Input the patient’s date of birth accurately, and select the correct gender by marking the appropriate option.
5. Complete the policyholder’s name field with the full name of the person holding the cancer policy.
6. Provide the cancer policy number or social security number of the policyholder in the specified section.
7. Fill in the street address of the policyholder, ensuring to check the box if the address has changed.
8. Enter the city, state, and zip code in the corresponding fields.
9. Include a telephone number where the policyholder can be reached, formatted in three sections.
10. Attach any necessary bills, receipts, or evidence of the tests undergone. This documentation is critical for verifying the claim.
11. Review all the information for accuracy before finalizing the document. Once complete, you can save changes, download, print, or share the form as required.

Complete your Fidelity Cancer Screening Reimbursement form online today to ensure you receive your benefits.