Get Liberty Healthshare Direct Primary Care (dpc) Reimbursement Request Form

The Liberty HealthShare Direct Primary Care (DPC) Reimbursement Request Form allows users to request reimbursement for monthly DPC membership fees. This guide provides clear and detailed steps to help users effectively complete the form online.

Follow the steps to accurately complete your reimbursement request form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date in the designated field using the mm/dd/yy format, as accurate dating is essential for processing your request.
3. Fill in the DPC practice name and location, ensuring that you provide the correct city and state for proper identification.
4. Select the type of DPC membership that applies to you: individual, couple, or family. Make sure to indicate any additional members as appropriate.
5. Input the amount of your monthly membership fee. This is crucial for determining the reimbursement amount.
6. Provide your membership information, including your name, membership ID number, and date of birth.
7. Complete your address details in the provided fields, ensuring accuracy for communication.
8. Indicate your phone number in the designated format to enable easy contact.
9. Check the boxes next to the health and cost savings services provided by your DPC practice that apply to you.
10. Initial each agreement statement to confirm your understanding and agreement with the terms outlined in the document.
11. Sign and date the form at the bottom to authenticate your request.
12. Once all sections are complete, review your form for accuracy, save your changes, and utilize the options available to download, print, or share your completed form.

Complete your Liberty HealthShare DPC Reimbursement Request Form online today for an efficient reimbursement process.