Get Direct Member Reimbursement Form - Unity Health Insurance

Completing the Direct Member Reimbursement Form for Unity Health Insurance is an essential step to ensure you receive reimbursement for your medication expenses. This guide offers a clear and supportive approach to assist you in filling out the form correctly online.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the Direct Member Reimbursement Form and open it in your preferred editor.
2. Fill out Part 1 with your personal information, including your member/cardholder ID number (found on your insurance card), your health plan name, and your relationship to the primary subscriber. Ensure that all required fields are completed to prevent delays.
3. In Part 2, provide all required prescription receipts/labels. If needed, ask your pharmacist to fill in this section. Remember to tape receipts to a separate page while ensuring they are not stapled to the form.
4. Double-check that you include all required information from your prescription labels, including date filled, RX number, quantity, day supply, national drug code (NDC), medication name and strength, and copay amount.
5. For pharmacy information in Part 3, if you do not have the necessary receipt, ask the pharmacist to complete this section with their signature, and provide the pharmacy's information.
6. Review the entire form for completeness, ensuring all required fields are filled out accurately, then save your changes.
7. Finally, download or print the completed form along with any receipts to submit them to the appropriate address or email as indicated.

Ensure your documents are filled out correctly online to expedite your reimbursement process!