Patient information

Loading receipt submission form

Tell us about your patient

Please enter the information of the patient on whose behalf you’re filing this claim reimbursement.

Patient information

Fields marked with an asterisk * are required.

You have [no_of_errors] field(s) that need to be corrected:

Also known as ID or RxID
Also known as GRP or RxGrp

Additional insurance plan

If you’re enrolled in an additional insurance plan on which you are not the primary policy holder, please add it here.

Additional insurance plan

[policy_holder_name]

[policy_contract_number]

[policy_insurance_carrier]

Tell us about you as a representative

Please enter your information below as well as the reasons the patient is requesting reimbursement. You’ll also need to upload a document as proof of your patient representation.

 

Fields marked with an asterisk * are required.

You have [no_of_errors] field(s) that need to be corrected:

Your proof of representation or guardianship

(e.g., CMS-1696, POA, guardianship papers, court orders, or health care proxy) [at least one, but could upload more] 

file
Drag and drop your file here or
Accepted file formats include .pdf, .jpg/.jpeg, and .png.

    Add receipts

    Loading reimbursement method and signature

    Receipts

    Please upload your pharmacy receipt as proof of purchase for your claim reimbursement. You must upload at least one file before continuing with the form. Please include a prescriber, a pharmacy, the prescription(s), and claim information associated with each upload.

     

    Please upload at least one receipt to continue.

    Add receipt

    Reimbursement method and signature

    Submission in progress

    Reimbursement method

    Please choose the mailing address you’d like your claim reimbursement sent to, should it be accepted.  If you’re filing as a patient representative and you choose to send the payment to a mailing address, please enter the patient’s address, not your own address. You’ll be asked to enter additional information depending on your choice of reimbursement method.

    Fields marked with an asterisk * are required.

    Select your reimbursement method

    Bank account information

    Fields marked with a red asterisk * are required.

    You have [no_of_errors] field(s) that need to be corrected:

    Mailing address

    Fields marked with a red asterisk * are required.

    You have [no_of_errors] field(s) that need to be corrected:

    Review and sign

    I acknowledge my request for reimbursement will be paid directly to me and any assignment of benefits to a pharmacy or any other party related to this claim is void. Parties agree entering my name electronically below shall have the same force and effect as an original signature.

    Terms and conditions

    Any person who knowingly and with intent to defraud, injure, or deceive any insurance company, submit a claims or application containing any materially false, deceptive, incomplete or misleading information pertaining to such claim may be committing a fraudulent insurance act which is a crime and may subject such person to criminal or civil penalties, including fines and/or imprisonment, or denial of benefits. I certify that the medication(s) for which reimbursement is requested were received for use by the member above, and that I (or the member, if not myself) am eligible for prescription drug benefits. I also certify that the medications received were not for treatment of an on-the-job injury.

    Additional insurance plan

     

    Tell us about your additional insurance

     

    Fields marked with an asterisk * are required.

    You have [no_of_errors] field(s) that need to be corrected:

    Additional insurance benefit payment notice

    Please upload a copy of your benefit payment notice from your additional insurance.

    file
    Drag and drop your file here or
    Accepted file formats include .pdf, .jpg/.jpeg, and .png.
      Also known as ID or RxID

      Receipt [receipt_number]

       

      Add receipt information

      Please upload and confirm  details of your pharmacy receipt to apply for claim reimbursement. You must upload a proof of purchase, assign at least one prescriber and pharmacy per upload, and include at least one prescription to request reimbursement.

      Please complete the required fields

      Upload receipt

      file
      Drag and drop your file here or
      Accepted file formats include .pdf, .jpg/.jpeg, and .png.

        Prescriber

        Add prescriber

        Add a prescriber

        Please add a prescriber

        [prescriber_name]

        [street_address]

        [city_state]

        Prescriber details

        You have [no_of_errors] field(s) that need to be corrected:

        Fields marked with an asterisk * are required.

        Pharmacy

        Add pharmacy

        Add pharmacy

        Please add a pharmacy

        [pharmacy_name]

        [street_address]

        [city_state]

        Pharmacy details

        You have [no_of_errors] field(s) that need to be corrected:

        Fields marked with an asterisk * are required.

        Enter the name of your pharmacy

        Prescription

        Add prescription

        Add another prescription

        Please add a prescription

        [medication_name]

        [medication_type]

        [quantity]

        [day_supply]-days supply

        Prescription details

        You have [no_of_errors] field(s) that need to be corrected:

        Fields marked with an asterisk * are required.

        (e.g., tablet, capsule, aerosal, etc.)

        (e.g., mg, mL, mcg, etc.)

        Total amount of medication per package
        Number of doses you receive per refill

        (e.g. 30-day, 90-day)

        11-digit number

        You can find the NDC of your prescription near the drug name on your bottle or package, or on your pharmacy receipt

        How to find your NDC

        The National Drug Code or NDC is a unique 11-digit, 3 segment identifier for your medication. You can find the NDC of your prescription near the drug name on your prescription bottle or package, or on your pharmacy receipt

        Please select the situation which best applies to this claim below.

        Please enter the date on which you were given this receipt. Fill date must be within the last 3 years.

        Your claim has been successfully submitted

        Submission Confirmation

        Checking your claim status

        Once your claim has been uploaded, you can check the current status of your reimbursement on your Claims page. Please allow up to 4-6 weeks for your claim to be fully processed. You can also print or download this page using the link in the top right.

         

        If your claim is rejected, we will promptly send a detailed letter explaining the reasoning behind the rejection. You can also contact us and ask about your claim using your confirmation number.  If you need further assistance, please feel free to contact us.

        Reimbursement method

        Mailing address

        [mailing_address]

        Bank Information

        [banking_summary]

        Patient and representative information

        Patient information

        [patient_name]

        [patient_dob]

        [patient_address]

        Patient insurance

        [patient_member_id]

        [patient_group_number]

        [patient_insurance_address]

        Additional insurance

        [policy_holder_name]

        [policy_contract_number]

        [policy_insurance_carrier]

        Patient representative

        [legal_rep_name]

        SSN/EID: [legal_rep_ssn]

        File: [legal_rep_proof]

        Address and contact information

        [legal_rep_email]

        [legal_rep_phone]

        [legal_rep_address]