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Copay Rebate Form REBATE INSTRUCTIONS: If your pharmacy does not accept or cannot process your RELIANT/RELIANT XR Copay Savings Card, use this Rebate Form to request reimbursement of your outofpocket

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How to fill out rebate instructions

01

Read the instructions carefully before starting the process.

02

Gather all the necessary documents and information needed to fill out the rebate form.

03

Fill out your personal information accurately, including your name, address, and contact details.

04

Provide the required purchase details, such as the date of purchase, product information, and store name.

05

Include any additional supporting documents, such as receipts or proof of purchase.

06

Double-check all the entered information for accuracy and completeness.

07

Submit the filled-out rebate form along with any additional documents through the specified method, such as mail or online submission.

08

Keep a copy of the filled-out form and any related documents for your records.

09

Follow up on the status of your rebate if necessary, using the provided contact information.

10

Once your rebate is approved, ensure to receive the rebate amount as specified in the instructions.

Who needs rebate instructions?

01

Anyone who has made a qualified purchase and is eligible for a rebate can benefit from following rebate instructions.

02

Customers who want to claim a rebate offered by a manufacturer or retailer.

03

Individuals or businesses seeking to receive a refund or discount on a product or service they have purchased.

04

People interested in maximizing their savings by taking advantage of rebate programs and offers.

05

Those who want to ensure their rebate application is correctly filled out and submitted to increase the chances of approval.

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