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Patient Mailing Refund Form
INSTRUCTIONS
To receive your reimbursement check within 6 to 8 weeks for a valid prescription claim, please complete the following steps:
1. Fill a 3month prescription
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How to fill out patient mail-in refund form
How to fill out patient mail-in refund form
01
Step 1: Download the patient mail-in refund form from the healthcare provider's website or request a copy at the receptionist desk.
02
Step 2: Fill in your personal information such as your full name, address, contact number, and date of birth.
03
Step 3: Provide details of the medical service or treatment for which you are seeking a refund.
04
Step 4: Attach all relevant supporting documents such as medical bills, receipts, and insurance claim forms.
05
Step 5: Clearly state the reason for the refund request and include any additional supporting information.
06
Step 6: Review the completed form for accuracy and make sure all required fields are filled.
07
Step 7: Sign and date the form.
08
Step 8: Make a copy of the completed form and supporting documents for your records.
09
Step 9: Mail the original form and supporting documents to the designated address provided by the healthcare provider.
10
Step 10: Follow up with the healthcare provider to ensure they have received your form and track the progress of your refund request.
Who needs patient mail-in refund form?
01
Patients who have made a payment for medical services or treatments and are eligible for a refund can use the patient mail-in refund form.
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