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1475 Kendale Blvd., P.O. Box 2560 East Lansing, Michigan 48826-2560 517.332.2581 800.292.4910 Fax: 517-333-6229 www.messa.org Claims Reimbursement Form Please complete this enre form and aach/include as much informaon as possible. Important Note: Your bill/receipt must accompany this form for processing. Please remember to aach your itemized bill/receipt for reimbursement consideraon. MESSA Member / Paent Informaon Claim Informaon Provider Informaon Reimbursement Instrucons (Please Print) First Name of Member First Name of Paent Address Address 2 City State Zip Code Work / School Phone # School District Home Phone # Last Name of Paent Paent’s Date of Birth (MM/DD/YY) Last Name of Member Enrollee ID Number ( ) ( ) ( ) Type of Service: Diagnosis: Individual Charge Detail for Each Type of Service: Diagnosis Code Number: Procedure Code: (i.e., lab, office visit, supply, x-ray) Name of Provider or Facility Address Address 2 City Zip Code State Naonal Provider Idenficaon (NPI) Number Telephone Number Tax ID Number Degree Send payment to: Member Provider MES - MS Rev. 2/24/14 Pr. 2/14 - 1PDF
