Find Care
Pharmacy
Support
Members
Brokers
Employers
Providers
Company
Member Portal
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*
Select plan type
Date of Service*
Total Amount Paid*
Did you pay for the service rendered?*
Choose an option
Did you complete your baseline visit?*
Choose an option
Have you already sent in a request for these services?*
Choose an option
Is this a claim for services performed outside of the United States?*
Choose an option
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.*
Choose an option
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)
Submit
We and our vendors use cookies to provide and personalize your experience on our site, and to perform analytics. For more information, see our
Privacy Policy.
