Prescription Reimbursement Claim Form
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1
214423-STANDARD-
0816
Prescription Reimbursement Cl a i m Form
Important!
•
Always allow up to 30 days for reimbursement.
•
Keep a copy of all the documents you send us.
•
Do not staple receipts or other documents to this form.
•
Reimbursement is not a guarantee.
STEP 1
Member Information
REQUIRED:
This section must be filled out completely.
Please check the reason you are submitting a
paper claim. If you do not check a reason, the
Card Holder Information
claim will be returned if you. Please tape
Passport Member ID Number
receipts or itemized bills on the back.
I am filing this form because:
Last Name
My pharmacy does not accept
Passport
MI
First Name
I am on a compound
I did not have insurance at the
Address
time
Other. Please write the reason
Address 2
here:
City
State
Zip
Member Information
Last Name
MI
First Name
Date of Birth
Male Female
Phone Number
Relationship to Primary Member
Other
Member
Spouse
Child
Pharmacy Information
Pharmacy Name
Address
City
State
Zip
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Parent category: Business