Get Brisdelle () Capsules Copay Program Reimbursement Form

Completing the Brisdelle® Capsules Copay Program Reimbursement Form can help you recover your out-of-pocket costs for this medication. This guide will provide step-by-step instructions to ensure you fill out the form accurately and efficiently.

Follow the steps to complete your reimbursement request successfully.

1. Click the ‘Get Form’ button to retrieve the Brisdelle® Capsules Copay Program Reimbursement Form and open it in your document editor.
2. In the ‘Patient Information’ section, enter your full name, address, contact number, email, date of birth, gender, and age. Ensure each field is accurately completed to prevent processing delays.
3. Proceed to the ‘Prescriber Information’ section. You will enter the prescriber's full name and contact details, including their address and phone number. This information should reflect exactly as provided by your healthcare provider.
4. Fill in details regarding your prescription or mail order provider in the designated field. Use clear and legible characters.
5. Ensure you have all necessary supporting documents ready to submit with this form. This includes a copy of your prescription label, co-pay savings card, and a dated original receipt for your co-payment. Highlight the amount paid on your receipt.
6. Review the eligibility requirements carefully. You must certify that your prescription usage does not involve federal or state healthcare programs as stated in the form.
7. Sign the form to verify that the information provided is complete and accurate, and consent to the necessary contact with your healthcare provider for verification.
8. Once all information is filled and verified, save your changes. You can now download, print, or share your completed form as needed.

Begin the reimbursement process by completing your Brisdelle® Capsules Copay Program Reimbursement Form online today.