HMO member reimbursement form for vaccines: Flu, Shingles, and Tdap/Td
Hill Physicians is not responsible for reimbursement for Tdap/Td shot (Boostrix®, Adacel®, Tenivac®, TDVAX®) or shingles shots (Zostavax®, Shingrix®). Please call your Medicare Part D 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 will reimburse up to $90 for the flu vaccine.
HMO Members (non-Medicare)
Hill Physicians will reimburse your vaccine cost up to $90 for the flu vaccine, up to $80 for the Tdap/Td shot (Boostrix®, Adacel®, Tenivac®, TDVAX®), and up to $275 for each dose of shingles shot (Zostavax®, Shingrix®).
- Fill out the form below.
- Attach 2 receipts (original pharmacy receipt and a copy of the cash register receipt). You must attach both receipts to receive reimbursement.