Get Medimpact Reimbursement Form

Filling out the Medimpact Reimbursement Form online is a straightforward process that ensures you can submit your prescription claims accurately. This guide will walk you through each section of the form, providing clear instructions to help you complete it effectively.

Follow the steps to fill out the Medimpact Reimbursement Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Complete Part 1 with all required member information. This includes your member ID number, which can be found on your insurance card, along with your name, date of birth, primary subscriber address, and contact information. Be sure to indicate your relationship to the primary subscriber.
3. In Part 2, provide the necessary receipt information. Attach all original pharmacy receipts that contain the required prescription details. If you do not have receipts, your pharmacist needs to complete the necessary sections. Remember not to staple any documents.
4. If needed, request your pharmacy to complete Part 3. Ensure that the pharmacist includes their signature and any other required pharmacy details on the claim form.
5. Review all sections to confirm that all required information is accurately completed. Pay close attention to any fields marked with an asterisk, as leaving them blank could result in your claim being returned.
6. Once you have filled out the entire form, save your changes. You can also download, print, or share the form for your records.
7. Submit the completed form along with the required receipts to MedImpact Healthcare Systems, Inc. using the provided mailing address, fax number, or email.

Start filling out your Medimpact Reimbursement Form online today to ensure a smooth and timely reimbursement process.