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Member Forms and Brochures

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Instructions to complete the reimbursement form for
Over-the-Counter (OTC) COVID-19 tests

Important: Complete a separate form for each member asking for reimbursement for covered services and for each doctor and/or facility. To avoid processing delays, please include the following information with this form:

  • Copy of itemized bill showing all services received. Must include name, address, phone number, tax ID number of doctor and/or facility, date of service and all diagnosis and procedure codes.
  • Proof of payment for reimbursement requests over $200. "Proof of Payment" includes: a copy of the credit card charge slip or online statement, canceled checks, a bank account statement, cash withdrawal slips, or a cruise ship statement. Note: Invoices are not acceptable proof of payment.
  • See the instructions in Section 4 for Foreign Claim Questionnaire for services received outside of the U.S

Other Forms

Please explain in detail the circumstances that led to your dissatisfaction with Health Net. Please include the original copy of any claims or bills received which are related to your issue.

For Healthy Families, Healthy Kids and AIM plan members. Medi-Cal members please contact Member Services.

Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.

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Last Updated: 04/13/2022