Claims Reimbursement Online Submission Form

For all non-prescription claim reimbursement requests including medical, dental or vision. Please enter the information below as found on your member ID card.
Employer Name:

Group #:

Member ID#:

Employee Name:

Patient's Name:

Patients Date of Birth (mm/dd/yyyy):

Email Address:

Type of Claim:

Additional Information:
Submission Options:
Submitting your claim for reimbursement is easy! The quickest way to receive your reimbursement is by completing this online form. You may upload an image of your itemized receipt and receive a check within 3-10 business days once the claim is processed. Or click here for instructions on setting up direct deposit (Electronic Funds Transfer – EFT) into your checking or savings account, and get your money electronically without having to deposit a check.

Attach Itemized Receipt:

By clicking here, you agree that your attached receipt is legible. If you are unable to read it, we will not be able to read it. You also ensure your receipt is complete and contains the following information:

  • Provider of service;
  • Detail of the service(s) rendered;
  • Diagnosis, if applicable.

You also agree that if your receipt does not contain this information or cannot be read clearly, you will not receive your reimbursement.


Paper Process:
Click here to download and print a paper form. After completion, scan and attach the form and your receipt to an email and send to:

You may also fax the paper form and your receipt to 1-915-581-7537, or mail to:
HealthSCOPE Benefits
P.O. Box 16203
Lubbock, TX 79490-6203
Please allow 4-8 weeks if faxing or mailing your form and receipt. Failing to include a form with your receipt, or a form with incomplete information may result in additional delays, or your reimbursement may not be processed.