Get the free **This form is for direct reimbursement to members for covered medical benefits unde...
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A copy of the receipt with the provider s name and address preprinted on the receipt. Mailing Information Mail this form and your itemized receipts to Did you remember To complete all applicable sections on Scripps Health Plan this form c/o Direct Member Reimbursements To attach itemized receipts for each 10790 Rancho Bernardo Rd. Date DMRLGHMO7 rev. 3/17/16 Reimbursement Request Itemized Statement Provide as much information as possible. Member Reimbursement Form This form is for direct...
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