1475 Kendale Blvd., P.O. Box 2560East Lansing, Michigan 48826-2560

517.332.2581 800.292.4910Fax: 517-333-6229

www.messa.org

Claims Reimbursement FormPlease complete this entire form and attach/include as much information as possible.

Important Note: Your bill/receipt must accompany this form for processing. Please remember to attach your itemized bill/receipt for reimbursement consideration.

MESSA Member / Patient Information

Claim Information

Provider Information

Reimbursement Instructions

(Please Print)First Name of Member

First Name of Patient

Address

Address 2

City State Zip Code Work / School Phone #

School District

Home Phone #

Last Name of Patient Patient’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 CodeState

National Provider Identification (NPI) Number

Telephone Number

Tax ID Number

Degree

Send payment to: Member Provider

MES - MSRev. 2/24/14Pr. 2/14 - 1PDF