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Fidelis care reimbursement form 2026

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The document outlines the Flex Benefit Reimbursement Form provided by Fidelis Care for members of their Medicare Advantage and Dual Advantage plans. It details the eligibility, reimbursement process, and types of health-related expenses that can be claimed. Members must submit receipts within 90 days for eligible items, which include dental services, fitness memberships, and durable medical equipment. The document emphasizes that benefits are personal and non-transferable, with unused amounts forfeited at year-end.

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Click ‘Get Form’ to open the Fidelis Care Reimbursement Form in the editor.
Begin by filling in your personal information, including your Member ID, name, address, and city/state/ZIP code. Ensure all details are accurate for a smooth processing.
In the section provided, check off the type of service you received. For each service, enter the date of service and the amount you paid. Remember to attach your original receipt that includes a description of the items purchased.
If applicable, complete additional fields for Medical Services Transportation by providing the provider's name and address along with the date of service.
Finally, read and attest to the statement confirming that items were purchased for personal use only. Sign and date the form before submission.

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