2023 Preventive Reimbursement Request

Formulario en Español

This form is for Health Access Solutions members. Please use this form to submit your eligible preventive expenses for reimbursement.

Reimbursement requests for eligible preventive services are only accepted from providers based in the United States, Canada, and Mexico.

Click here for a complete list of expenses that are eligible for reimbursement.
Primary Member Details
Please enter the name of the primary Health Access Member and their Member ID.
Don't know your Health Access Member ID? Click here to look it up.
Primary Member Name
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Required First Required Last
Primary Member ID *
N/A

Please Note: The first 3 digits of the Health Access Member ID will always be 522, 142 or 143. If you enter a Member ID from Zion, Sedera etc., your reimbursement request may be delayed.
Patient Details
Please enter the details for each patient and visit. Click the '+' to add additional patient visits.

Category Examples:
- Basic Wellness & Lab – Yearly physical, wellness labs, immunizations, mammograms, and colonoscopies.
- Physical Health / Fitness – Gym memberships and fitness training.
- DPC Monthly Fee – Direct Primary Care monthly membership fee.
-- No Fields Available --
- Patient Name
- Category
- Date of Service
- Amount
Add Entry Add Entry
- Patient Name
  N/A
  
  Required First Name Required Last Name
- Category *
  N/A
- Date of Service *
  N/A
  
  MM/dd/yyyy
- Amount USD *
  N/A
- Patient Name
  N/A
  
  Required First Name Required Last Name
- Category *
  N/A
- Date of Service *
  N/A
  
  MM/dd/yyyy
- Amount USD *
  N/A
- Total:
  USD
Attach your Receipt(s)

Maximum file uploads: 5
*
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Upload file
IMPORTANT NOTES: All reimbursement requests must include an itemized receipt (a breakdown of services received), the name of the provider, and the provider contact details.
Notes
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Is there anything you would like us to know about this request?
Please note:

After your reimbursement request has been processed, you will receive an email from Health Access via our secure payment provider Checkbook.io from the email address support@checkbook.io

Utilizing our secure payment provider, you will be able to receive your preventive reimbursements in the following ways:
- Direct Deposit (ACH)
- e-Check (Print & Deposit)
- Physical check via US Mail
N/A

Receive Text Notification? Sending Text Not Sending Text Receive Text Notification?

When checked, you will receive a text notification when your request has been approved. You can reply STOP to no longer receive text messages.
Would you have gotten this service if you did not have this benefit?
*
N/A

Yes
No
Terms and Conditions *
N/A

My signature below affirms that the expenses listed in the attached provider receipt were incurred by me or my eligible family members.
Expenses must be submitted within the calendar year the services were provided and no later than March 1st of the following year.
Preventive reimbursement payments will be valid for 60 days.
Lost or stolen checks can be reissued 60 days after original issue date.
Reimbursed expenses cannot be claimed as credits or deductions on your personal income tax.
Reimbursement requests for eligible preventive services are only accepted from providers based in the United States, Canada, and Mexico. If the services were rendered by a provider outside the United States, you may be asked to provide the following items: a copy of a financial statement showing the transaction came from an account under your name and an itemized receipt of the services you received.
By submitting this form and signing up for texts, you consent to receive text messages from Health Access Solutions at the number provided. Msg & data rates may apply.

I agree.
Signature *
N/A

E-Signature Field
Clear
Status
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SubmittedDate
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MM/dd/yyyy

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