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Get Tufts Health Plan Prescription Reimbursement Form

E plus claims processing. * Make a copy of all documents submitted and do not staple or tape receipts or attachments to this form. No documents will be returned. Primary Member/Patient Information This section must be fully completed to ensure proper reimbursement of your claim. Primary Member Information Identi cation Number (refer to your prescription card) Group No./Group Name Name (Last Name) (First Name) (MI) Address State City Zip Patient Information Use a separate claim for.

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