Member Reimbursement Form

Complete the member reimbursement form and a member of our team will be in touch.

First Name*

Last Name*

Email*

Curative Member ID*

Member Name*

Member Date of Birth*

Home Address*

Employer Name*

Plan Type*

Date of Service*

Total Amount Paid*

Did you pay for the service rendered?*

Did you complete your baseline visit?*

Have you already sent in a request for these services?*

Is this a claim for services performed outside of the United States?*

I certify that the above information is accurate and that the submitted documents are true and correct. I understand that submission does not guarantee reimbursement.*

Upload the following three documents (PDF only):

Superbill or itemized statement (must include the provider's NPI number)
Paid receipt
Transaction statement (e.g., bank or credit card statement showing payment)