Get Ripae Reimbursement Application - Rhode Island Division Of ... - Dea State Ri

Filling out the RIPAE Reimbursement Application is an essential step for individuals seeking financial assistance for prescription drugs while in the coverage gap. This guide provides step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete your application online.

1. Press the 'Get Form' button to access the application. This will enable you to open the form in an editing tool.
2. Begin filling out the personal information section by entering your Social Security Number in the designated field. Ensure that this number is accurate, as it is crucial for processing your application.
3. Complete the name section by providing your full name. This should match the name on your legal documents.
4. Provide your residential address in the Street Address, City/Town, and Zip Code fields. This information allows the department to communicate with you effectively.
5. Enter your Medicare Number as shown on your red, white, and blue card. This ensures accurate identification for your Medicare benefits.
6. Fill in your telephone number and email address, if available. This information is beneficial for follow-up communication regarding your application.
7. Indicate your RIPAE Member ID Number if you have one. This helps reference your existing account or application.
8. Provide your date of birth in the specified format. This information is necessary for identity verification.
9. Complete the fields regarding the number of daily medications, generic drugs, and brand drugs you are currently using. Accurate entries here are vital for determining your eligibility for reimbursement.
10. Fill in your RIPAE Group ID Number, if applicable, to facilitate the processing of your claim.
11. Attach the approved documentation as required. Circle 'Yes' or 'No' in response to whether the documentation is attached.
12. Provide the name and ID number of your Medicare Part D Plan. This is necessary for processing your claims accurately.
13. Review the disclaimer and confirm your understanding of the rights and responsibilities associated with the application by providing your signature and date.

Complete your RIPAE Reimbursement Application online to ensure you receive the support you need.