Community Health Plan offers a Member Reimbursement Form for those who need to be reimbursed for purchased services from a health care provider.

To complete the Member Reimbursement Form, simply:
1. Fill in the legal name of the person who paid for services along with mailing.
2. Fill in the legal member's name, date of birth, policy number found on your Community Health Plan member ID card and group number.
3. Fill in your health care provider's name, tax id number, address, and telephone number if available.
4. Fill in the date services were rendered, the amount the member paid, and type of transaction such as check, cash, credit card, etc.
5. You may also fill in any comments or concerns. Please provide your telephone number and what time of day you may be contacted to ensure a quick turnaround on your request.

Once you've completed the Member Reimbursement Form, attach a copy of your invoice, a copy of your transaction receipt or any documentation provided by the health care provider’s office to verify proof of payment and services rendered.