Hearing Aid Reimbursement Claim Form - carpdc.org:82 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by filling out the Member Information section. Enter your last name, first name, middle initial, date of birth, and Coventry ID or SSN. Don’t forget to include your home and cell phone numbers along with your address details.
  3. Next, move to the Physician or Provider & Claim Information section. Indicate whether the claim is for the right or left ear, provide the diagnosis, date of service, place of service, procedure code, and charges for each ear.
  4. Ensure that your physician or provider completes their section by providing their name, address, phone number, and signature along with the date.
  5. In the final part of the form, certify your reimbursement request by signing and dating where indicated. Make sure you understand the certification statement regarding reimbursement eligibility.

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