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Member Claim Forms

Use these forms to submit claims.


Claim Forms

Dental Claim Form

Use this form to submit claims and expenses for preventive dental care you received. 

Fitness Claim Form*

Use this form to request for Vibra Health Plan to pay for our share of the cost for wellness programs. Your coverage allows up to $90 per quarter for gym memberships, fitness classes, and exercise programs. Only* for Vibra Health Plan Enhanced Coverage PPO plan.

Member Claim Form

Use this form to submit claims and expenses for medical care or a drug you received.

Transportation Claim Form

Use this form to submit claims and expenses for transportation.

Vision Claim Form

Use this form to submit claims and expenses for routine vision care you received.

Updated October 1, 2018
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