Get the free USE THIS FORM TO REQUEST REIMBURSEMENT FOR CLAIMS THAT YOUR PHARMACY DIDN'T PROCESS

USE THIS FORM TO REQUEST REIMBURSEMENT FOR CLAIMS THAT YOUR PHARMACY DIDN\'T PROCESS UNDER YOUR INSURANCE. Cardholder Name:Cardholder ID:Patient Name:Patient DOB:Cardholder Address:City/State:ZIP CodePhone Number: Is this a Coordination of Benefits Claim?YesNoInternal Use Only: Episode Number:Please include a pharmacy receipt for each medication to avoid denial and/or delays in processing your case. A cash register receipt alone cannot be used to process your claims. All information

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