Request a reimbursement


DOWNLOAD THE FORM

  • Complete one form for each patient and incident.
  • If you have another medical insurance policy, the application for reimbursement must first be processed by the other insurance company and then submitted to Bupa with an explanation of how the reimbursement was processed.
  • If you want an ELECTRONIC REIMBURSEMENT, you must also complete the following form:

DOWNLOAD
AUTHORIZATION FORM FOR ELECTRONIC
REIMBURSEMENT OF CLAIMS
( 164 Kb. )


DOWNLOAD
FORM TO REQUEST A REIMBURSEMENT
( 32 Kb. )



READ THE INSTRUCTIONS BEFORE COMPLETING THE FORM
  • Remember to sign the form
  • Use UPPER CASE LETTERS to complete all the sections of the form.
  • Ask your healthcare provider to sign and stamp the form
  • Include all original invoices with the corresponding payment receipt
  • Make sure we get a copy of the history of your illness or current condition

ONCE YOU HAVE COMPLETED IT, SEND IT

  • BY MAIL to:
    Bupa Insurance Company
    17901 Old Cutler Road, Suite 400
    Palmetto Bay, FL 33157
  • BY EMAIL:
    bupa@bupalatinoamerica.com

    If you have any questions, contact us at +1 (305) 398 7400