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Retinal eye exam reward form for members with diabetes

If you received a retinal exam and didn't use your HAP coverage, fill out this form to get your reward. Prefer to print your form and mail it in? Print or download a copy (PDF).

Note: If you have more than one eligible person in a household, please fill out a separate form for each person.

Untitled Form

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Contact us

  • HAP Medicare Sales:

    (800) 868-9885 (TTY: 711)

  • HAP Senior Plus®

    (800) 801-1770 (TTY: 711)

  • HAP Senior Plus®(PPO)

    (888) 658-2536 (TTY: 711)

  • Alliance Medicare Supplement:

    (800) 873-7526 (TTY: 711)