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

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

REIMBURSEMENT REQUEST DIRECT PRIMARY CARE (DPC)DPC REQUEST INFO Month/Year for DPC Membership Fee RequestDate (mm/dd/yy)*Request considered invalid after 3 monthsDPC Practice NameDPC Practice Location.

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Medical Expenses $200 or less in billed charges (per visit/per member) are not to be submitted and are ineligible for sharing, unless otherwise noted in the guidelines. Ineligible expenses cannot be applied to a Member's Annual Unshared Amount (AUA).

Submitting bills Members login to their member portal to submit bills. Eligible expenses will be reimbursed by Liberty HealthShare.

Liberty HealthShare is not insurance.

Electronically: LHS Electronic Payer ID: 90753. Mail: P.O Box 35691, Canton, OH 44735.

Because Liberty HealthShare does not have a recommended provider network, members are free to choose their own providers.

You can cancel at any time. If you want to cancel, you should send written notice of your cancellation, including the reason for cancellation, by the 25th day of the month, prior to the month in which your sharing contributions will end.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232