Member Vaccination Reimbursement

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.
Medicare Members
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.
Reimbursement Amounts 
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.