Get Signature / Release

Filling out the SIGNATURE / RELEASE form is a crucial step to ensure a smooth reimbursement process for your prescriptions. This guide provides clear, step-by-step instructions to assist users in accurately completing this document online.

Follow the steps to complete the SIGNATURE / RELEASE form online.

1. Press the ‘Get Form’ button to access the SIGNATURE / RELEASE form and open it in your document editor.
2. Start with the cardholder information. Input the cardholder ID number, RxGRP number, name, plan sponsor, phone number, and address, including city, state, and zip code.
3. Next, fill in the member information. Provide the name, relationship to the cardholder (primary, spouse, or child), date of birth in DD/MM/YYYY format, gender, phone number, and address details.
4. Proceed to the SIGNATURE / RELEASE section. Read the certification statement carefully, ensuring you understand that by signing, you authorize the release of information regarding your claim. Then, enter the signature of the member, parent, or guardian, print the name, and add the date.
5. For prescriptions needing reimbursement, gather original itemized receipts. If you do not have these receipts, your pharmacist can assist you in completing the form.
6. If submitting prescriptions, fill out the relevant details for each medication including Rx number, strength, date filled, NDC, day supply, quantity, prescriber DEA number, pharmacy NABP number, and total cost. Repeat as necessary for multiple prescriptions.
7. For compound medications, ensure the pharmacist completes the designated area with ingredients, quantity, and cost, including their signature.
8. Once all fields are entered, ensure all information is accurate. Save changes to the document, and then download or print the completed form for submission.

Complete your documents online effortlessly to ensure timely processing of your claims.