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hi dr shito maharaj vice president and medical director here at impact health sharing today we're going to discuss what you need to do to submit a medical expense form you can complete your medical expense form online by visiting impacthealthsharing.com forward slash forms then selecting medical expense form completing a medical expense form requires detailed information please provide as much information you can to ensure timely processing missing information will result in delayed processing if you are completing this form for a medical provider one of the most important things is to ask your provider for the cms 1500 also known as a hikva form or a ub04 form to submit on their behalf if your provider facility can't give you that specific form you can ask for a super bill or an itemized bill but it must contain the following information the doctor's name provider's billing address which is not always the same as their physical address tax id number icd-10 code also known as diagnosis code cpt code also known as a procedure code any applicable modifiers a full breakdown of charges by service anesthesia minutes if applicable total charged total discounts if any total paid receipt showing payment again it is best if you can ask your provider for the hicfa form or the ub04 form as that will contain all the information we need to process your claim if you are submitting the medical expense form for a prescription please ask your pharmacy for an itemized summary of your prescription we specifically need the following information name of who the prescription is being dispensed for the prescriber's name the date prescription was filled medication name dosage quantity dispensed pharmacy name and address total charge which is usually on the receipt and receipt of payment the above information is often listed on your prescription bottle or is on the written information given to you when you get your prescription so you can simply submit a photo of the bottle ensuring the necessary information is visible together with the receipt of payment for us to process if you have any questions we are happy to help get you those answers please call us at 1-855-378-6777