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

*Asterisk indicates a required field.

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HAP Senior Plus® HMO, HMO-POS, and PPO are health plans with a Medicare contract. Enrollment in these plans depends on contract renewal. HAP Senior Plus® PPO is a product of Alliance Health and Life Insurance Company, a wholly owned subsidiary of HAP. Alliance Medicare Supplement is a product of Alliance Health and Life Insurance Company, a wholly owned subsidiary of HAP.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

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  • HAP Medicare Sales:

    (800) 868-9885 (TTY: 711)

  • (800) 868-3153 (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)