What kind of claim are you wanting to get reimbursed for?

Select the form:

Vision

Don't want to fill out the reimbursement online? Print the form here.

An Itemized receipt is Required for any reimbursement

Policy Information

Policy Holders First Name

Policy Holders Last name

Group Name

Home Mailing Address

City

State

Zip

Reimbursement Information

Up to 4 reimbursements allowed per submission

Patient First Name

Patient Last name

Patients Month of Birth

Patients Day of Birth

Upload Itemized Receipt

File #1 (Required)

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Add files

Upload Itemized Receipt

Additional File (Optional)

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Upload Itemized Receipt

Additional File (Optional)

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Upload failed. Max size for files is 10 MB.

Add Reimbursement

Reimbursement Information

Patient First Name

Patient Last name

Patients Month of Birth

Patients Day of Birth

Upload Itemized Receipt

File #2 (Optional)

Uploading...

fileuploaded.jpg

Upload failed. Max size for files is 10 MB.

Add Reimbursement

Reimbursement Information

Patient First Name

Patient Last name

Patients Month of Birth

Patients Day of Birth

Upload Itemized Receipt

File #3 (Optional)

Uploading...

fileuploaded.jpg

Upload failed. Max size for files is 10 MB.

Add Reimbursement

Reimbursement Information

Patient First Name

Patient Last name

Patients Month of Birth

Patients Day of Birth

Upload Itemized Receipt

File #4(Optional)

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fileuploaded.jpg

Upload failed. Max size for files is 10 MB.

Other Coverage Information

Does patient have other Vision coverage?

If yes, name of other insurance

Policy # for other coverage

Effective Date for other coverage

Policy Holder Signature / Contact Info

Policy Holder SignaturePolicy Holder Email

DatePolicy Holder Phone #

By checking this box, you are confirming the contact information and signature above were completed by the Policy Holder.

Your Reimbursement form has been successfully submitted. You will receive confirmation once this claim has been processed. Please allow 5 business days before checking the status of this reimbursement.

If you submitted wrong information, or have any questions, please reach out to Vision@samerahealth.com.
‍

Home

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Dental

Don't want to fill out the reimbursement online? Print the from here.

An Itemized receipt is Required for any reimbursement

Policy Information

Policy Holders First Name

Policy Holders Last name

Group Name

Mailing Address

City

State

Zip

Reimbursement Information

Up to 4 reimbursements allowed per submission

Patient First Name

Patient Last name

Patients Month of Birth

Patients Day of Birth

Upload Itemized Receipt

File #1 (Required)

Uploading...

fileuploaded.jpg

Upload failed. Max size for files is 10 MB.

Add Reimbursement

Other Coverage Information

Does patient have other Dental coverage?

If yes, name of other insurance

Policy # for other coverage

Effective Date for other coverage

Signature / Contact Info

Employee SignatureEmail

DatePhone #

Your Reimbursement has been successfully submitted. You will receive confirmation once this claim has been processed. Please allow 5 business days before checking the status of this reimbursement. If you submitted wrong information, or have any questions, please reach out to Claims@samerahealth.com.

Home

Oops! Something went wrong while submitting the form.

Medical

Don't want to fill out the reimbursement online? Print the form here.

An Itemized receipt is Required for any reimbursement

Policy Information

Policy Holders First Name

Policy Holders Last name

Member ID #

Mailing Address

City

State

Patient Information

Zip

Patient First Name

Patient Last name

Patients Month of Birth

Patients Day of Birth

Other Coverage Information

Does patient have other medical coverage?

If yes, name of other insurance

Policy # for other coverage

Effective Date for other coverage

Additional Information

Is treatment related to an injury?

If yes, please describe How, When and Where the accident took place.

Provider Information

If this is not applicable, please enter NA in fields below.

Provider Name/ Facility

Address

NPI

TAX ID

Phone #

Services Rendered
This information will need to be obtained from your provider, if not listed on your receipt.

If this is not applicable, please enter NA in fields below.

Date of Service (One Per Reimbursement)

Dx Codes (separate with a comma)

CPT Codes (separate with a comma)

Amount Paid

Form of Payment

Email Signature

Phone #Date

By checking this box you are confirming the contact information above is for the Policy Holder.

Upload Itemized Receipt

Max file size 10MB.

Uploading...

fileuploaded.jpg

Upload failed. Max size for files is 10 MB.

Your Reimbursement form has been successfully submitted. You will receive confirmation once this claim has been processed. Please allow 14 business days before checking the status of this reimbursement.
‍
If you submitted wrong information, or have any questions, please reach out to Info@samerahealth.com.

Home

Oops! Something went wrong while submitting the form.

What kind of claim are you wanting to get reimbursed for?

Select the form:

Vision

Policy Information

Reimbursement Information

Reimbursement Information

Reimbursement Information

Reimbursement Information

Other Coverage Information

Policy Holder Signature / Contact Info

Dental

Policy Information

Reimbursement Information

Reimbursement Information

Reimbursement Information

Reimbursement Information

Other Coverage Information

Signature / Contact Info

Medical

Policy Information

Patient Information

Other Coverage Information

Additional Information

Provider Information

If this is not applicable, please enter NA in fields below.

Services Rendered This information will need to be obtained from your provider, if not listed on your receipt.

If this is not applicable, please enter NA in fields below.

Services Rendered
This information will need to be obtained from your provider, if not listed on your receipt.