Rergence of washington member reimbursement form 2026

1. Click ‘Get Form’ to open the rergence of washington member reimbursement form in the editor.
2. Begin by entering your personal information in the 'MEMBER INFORMATION' section. Fill in the patient's name, date of birth, sex, and relationship to the policyholder.
3. Next, provide the policyholder's details including their name, address, and ID number. Ensure you write your ID number on the top of each page for easy reference.
4. In the 'OTHER INSURANCE INFORMATION' section, indicate if you or any family members have additional medical, dental, or prescription coverage. If applicable, complete the required fields regarding other insurance policies.
5. Tape your original receipts in the designated boxes on page two. Remember that cash register receipts will not be accepted; retain copies for your records.
6. Finally, sign and date the form at the bottom before mailing it to Regence BlueShield at the provided address.

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