Hill form zostavax 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Doctor’s Name and Health Plan Name in the designated fields.
3. Input your Subscriber ID number, which can be found on your insurance card, ensuring accuracy for processing.
4. Fill in your First and Last Name, followed by your Street Address, City, State (CA), and Zip Code.
5. Provide the Date of Birth for the person receiving the vaccination and include a valid Phone Number with Area Code.
6. Indicate where the service was performed and enter the Pharmacy’s TIN (tax ID) as required.
7. Attach both original pharmacy receipt and cash register receipt before submitting the form.
8. Mail the completed form to Hill Physicians Medical Group at the specified address by December 31, 2014.

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