Get Rx Copay Form - 2011

Filling out the Rx Copay Form - 2011 can be a straightforward process when conducted online. This guide provides step-by-step instructions to help you successfully complete the form, ensuring you receive the reimbursement you are entitled to.

Follow the steps to complete the Rx Copay Form - 2011 online.

1. Press the ‘Get Form’ button to secure a copy of the Rx Copay Form - 2011 and open it for editing.
2. Fill in your member information. Provide your full name, birth date, social security number (last four digits masked), street address, city, state, and zip code. Indicate your plan status — single, two-person, or family.
3. Enter claimant information. If the claimant is different from the member, fill in their name, birth date, and their relationship to you.
4. Provide pharmacy or provider information. Include the name of the pharmacy or provider, their telephone number, and their NABP number or tax ID number. Additionally, fill in the street address, city, state, and zip code of the pharmacy or provider.
5. Prepare your documentation for prescription co-payment reimbursement. Attach either the Medco printout or pharmacy receipts that indicate expenditures and co-payments.
6. For medical co-payment reimbursement, attach the Explanation of Benefits from your medical plan.
7. Review the completed form to ensure all required fields are filled accurately. Sign and date the authorization to release information section.
8. After finalizing your form, you can save changes, download, print, or share the form as necessary.

Start completing your documents online today to ensure timely reimbursement.