Transcription of Doctor or Facility who provided the care or services
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Doctor or Facility who provided the care or services
Doctor or Facility who provided the care or services Name_____ Address_____ City _____ State_____ ZIP_____ Phone Number_____ Doctor or Facility who referred you for the care or services , (if applicable) Name_____ Address_____ City _____ State_____ ZIP_____ Phone Number_____ What city and country were you in when you received medical care or supplies? _____ 7/13/2021
For foreign travel, fill out one form for each member for the entire trip. There is a separate form for prescription drug reimbursement. Exception: You can use this form for both medical and prescription drugs for foreign travel. Send the completed form and paperwork to the Medical Claim Address on the back of your member ID card.
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