Get Restat Fax Forms

The Restat Fax Forms are designed to facilitate reimbursement for prescription drugs purchased under specific conditions. This guide provides clear instructions to ensure accurate completion of the form and successful submission for reimbursement.

Follow the steps to complete the Restat Fax Forms online efficiently.

1. Click ‘Get Form’ button to obtain the Restat Fax Forms and access them in the designated online editor.
2. Fill out the top portion of the form with accurate information. Ensure each field is completed fully to prevent delays.
3. Attach a copy of your prescription receipt to the form. This must include essential details such as the pharmacy name, patient name, prescription number, and cost.
4. Enter the cardholder’s identification number, the 4-digit carrier/plan/group code, and the person code assigned to the family member for whom you are claiming.
5. Clearly print the cardholder's name and complete the cardholder's address section, including street, city, state, and zip code.
6. Provide the patient’s full name, date of birth, and specify their sex by circling 'M' or 'F'.
7. If applicable, include information for any other insurance plans, providing the employer and insurance company name.
8. Read the certification statement and sign the form to confirm all information provided is accurate.
9. Once completed, do not send any forms until the prescription card is received. Fold the form with the address on the outside, affix postage, and mail it to Restat at the specified address.

Complete the Restat Fax Forms online today to ensure a smooth reimbursement process.