Get Patient Redemption Form -

This guide provides clear instructions on how to complete the Patient Redemption Form online. By following these steps, you can successfully submit your claim to reduce your out-of-pocket costs on prescriptions and refills.

Follow the steps to complete your Patient Redemption Form effectively.

1. To begin, click the ‘Get Form’ button to access the Patient Redemption Form and open it in your editor of choice.
2. Fill in your personal information in the Patient Information section, including your name, date of birth, address, and contact numbers.
3. Next, provide the details of your insurance provider, including your Cardholder ID and program group number.
4. In the Pharmacy and Prescription Information section, fill in the pharmacy name, address, medication name, and prescription number. Additionally, include the medication fill date, quantity dispensed, and the amount you paid.
5. Circle the price you paid for as shown on your original prescription receipt, ensuring it contains all necessary details.
6. Sign the form to confirm your understanding and acknowledgment of the eligibility criteria outlined in the instructions.
7. Enclose the original pharmacy receipt, prescription label, and the completed Patient Redemption Form in an envelope.
8. Mail the envelope to the designated address: Patient Rebate, PO Box 2914, Phoenix, AZ 85062-2914, and keep a copy of the documents for your records.
9. If your claim qualifies for reimbursement, expect a check within 2 to 4 weeks after submission.

Complete your Patient Redemption Form online today and take the first step toward reducing your out-of-pocket costs!