HMO member reimbursement form:
For vaccines: Flu, Shingles, and TDaP
Please complete and submit this form if you paid out of pocket to receive the flu, tetanus / whooping cough (Boostrix®, Adacel®), or shingles shot (Zostavax®, Shingrix®) at a pharmacy. You may only use this form if you have health insurance that is not through Medicare.
If you are a Medicare member, please call your Medicare PartD insurance company to see if they will pay for you to get the vaccine at a pharmacy, or if they only pay for the vaccine in your doctor's office. Hill Physicians is not responsible for reimbursement for Medicare patients.
Hill Physicians will reimburse your vaccine cost up to $60 each for the flu shot and the tetanus/whooping cough shots. Hill Physicians will reimburse your vaccine cost up to $250 for each dose of any of the above shingles shot.
Reimbursement Steps for non-Medicare members
1. Fill out the form below.
2. Attach 2 receipts (original pharmacy receipt and a copy of the cash register receipt). You must attach both receipts to receive reimbursement.