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Prescription Drug Claim Form Prescription Benefit Managers PLEASE READ CAREFULLY BEFORE COMPLETING THIS FORM Use this claim form to request reimbursement for prescription drugs purchased: Between

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1. Begin by flipping the document over and locating the section labeled "please read reverse side."
2. Read the information provided on the reverse side carefully, paying attention to any instructions or details mentioned.
3. Take note of any additional forms or attachments that may be required to complete the process mentioned on the reverse side.
4. Fill out the necessary information on the front side of the document as instructed.
5. Once the front side is completed, flip the document back over and proceed to the "please read reverse side" section.
6. Determine if any further action is required based on the instructions given on the reverse side.
7. If the reverse side requires additional information, provide the requested details accurately and legibly.
8. Double-check your answers and ensure that all required fields are filled out.
9. Sign and date the document if necessary.
10. Keep a copy of the completed document for your records.

Anyone who is filling out a document that contains a "please read reverse side" section needs to read and follow the instructions on the reverse side. This can be relevant for various situations such as filling out applications, contracts, agreements, or legal forms. It is important to understand and comply with the information provided on the reverse side to ensure that the document is completed correctly.

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To fill out please read reverse side, simply follow the instructions provided on the back side of the document or form.

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The purpose of please read reverse side is to provide additional information, instructions, or important details that complement the content on the front side of the document or form.

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