Member Vaccine Reimbursement - Hill Physicians Medical Group

HMO member reimbursement form for vaccines: Flu, Shingles, and Tdap/Td

Medicare Members

Hill Physicians is not responsible for reimbursement for Tdap/Td shot (Boostrix®, Adacel®, Tenivac®, TDVAX®) or shingles shots (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 (Shingrix®).

Reimbursement Steps

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.

First and last name(Required)

Date of birth(Required)

mm/dd/yyyy

Preferred phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Vaccines given:(Required)

Flu

Tdap/Td

Shingrix Dose 1

Shingrix Dose 2

Attach a copy of the original pharmacy receipt(Required)

Max. file size: 100 MB.

Please use the .jpg file type.

Attach a copy of the cash register receipt(Required)

Max. file size: 100 MB.

Please use the .jpg file type.

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