44Reimbursement Request Form Subscriber Name La ID: 897803
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1 4 4 Capital Health Plan
4 4 Capital Health Plan Reimbursement Request Form Subscriber Name: Last Middle Initial Subscriber’s ID # (Located on front of card) : Telephone Number : Member Requesting Reimbursement Name (If subscriber): Member ID: Relationship to Subscriber: Note: If approved, your Member Services at 850 - 383 - 33 11. Type of Reimbursement (Please select one):Eyeglasses (applies to Medicare plans only $150 limit every 2 years):Please attach an itemized receipt which includes the follow Additional Information: Please include each item and check off the boxes below:This completed form. Subscriber’s Signature Date Mail completed form to: Capital Health Plan Claims DepartmentPo Box 15349Tallahassee, FL 323175349