Get Rebate Form

Filling out the Rebate Form online is a straightforward process that can help you save on out-of-pocket costs for your mail-order prescriptions of . This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and submit it successfully.

Follow the steps to ensure your rebate request is processed smoothly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Carefully fill out the patient’s full name, date of birth, address, city, state, ZIP, email (optional), and phone number. Ensure that all information is accurate and legible.
3. In the certification section, read the statements provided. By signing, you confirm that all the information submitted is true and that the prescription was not purchased through federal or state insurance programs.
4. Sign and date the form to validate your request.
5. Collect the Mail-Order Pharmacy Receipt, ensuring it includes critical details like the patient's name, Rx number, fill date, drug name, NDC number, pharmacy name, quantity, and price.
6. Prepare to submit your form. You can save changes, download, or print the completed form for mailing.
7. Mail the completed form along with the Mail-Order Pharmacy Receipt to the specified address: AZ Claims Processing Dept, PO Box 7017, Bedminster, NJ 07921-7017.

Complete your Rebate Form online today to take advantage of potential savings on your mail-order prescriptions.