Get Welldynerx Reimbursement Form

Filling out the Welldynerx Reimbursement Form accurately is essential for a smooth reimbursement process. This guide provides clear, step-by-step instructions on how to complete the form online, ensuring that you submit all necessary information correctly.

Follow the steps to complete your reimbursement form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the employee information section with the employer's name and your last name. This identifies the individual submitting the claim.
3. Complete the patient information section. Provide the patient's last name, first name, group number, birthdate, cardholder ID, and address. Indicate the relationship of the patient to the employee.
4. In the prescription sections (up to six), enter the Rx number, date filled, quantity, days supply, amount paid, and medication details including name, strength, and NDC number for each prescription. Check the appropriate boxes to indicate if the drug is a new prescription, refill, compound Rx, or allergy injectable.
5. Ensure that you include the original receipt from the pharmacy that includes prescription details. Photocopies or cash register tapes will not be accepted.
6. Include the pharmacy's complete name, address, city, state, zip code, and telephone number.
7. Review all the entered information for accuracy. Verify that there are no missing fields and that all requested information is complete.
8. Sign and date the form to certify that the information provided is correct and that the patient is eligible for benefits. This step is crucial for the submission to be processed.
9. Once completed, save the changes, and you can download, print, or share the form as needed before mailing it to the designated address: WELLDYNERX, PO BOX 4517, ENGLEWOOD, CO 80155.

Start filling out your Welldynerx Reimbursement Form online today to ensure a timely reimbursement.