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

Reimbursement Information

Up to 4 reimbursements allowed per submission
File #1 (Required)
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Add Reimbursement
Add Reimbursement
Add Reimbursement

Other Coverage Information

Signature / Contact Info

Thank you for submitting your reimbursement. Please allow 1-2 weeks to process. If you submitted wrong information, or have any questions, please reach out to Vision@samerahealth.com.
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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

Patient Information

Other Coverage Information

Max file size 10MB.
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Thank you for submitting your reimbursement. Please allow 1-2 weeks to process. If you submitted wrong information, or have any questions, please reach out to Claims@samerahealth.com.
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Medical

Don't want to fill out the reimbursement online? Print the form here.
An Itemized receipt is Required for any reimbursement

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.

Date of Service (One Per Reimbursement)
Max file size 10MB.
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Thank you for submitting your reimbursement. Please allow 1-2 weeks to process. If you submitted wrong information, or have any questions, please reach out to Info@samerahealth.com.
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Oops! Something went wrong while submitting the form.