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Get Rebate Form
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How to fill out the Rebate Form online
Filling out the Rebate Form online is a straightforward process that allows you to request reimbursement for your co-pay costs. This guide provides clear and concise instructions to help you successfully complete the form.
Follow the steps to complete the Rebate Form.
- Press the ‘Get Form’ button to obtain the rebate form and open it in your preferred editor.
- Provide your personal information in the designated fields, including your name, address, city, state, ZIP code, phone number, and email.
- Locate your member ID number from your Co-pay Savings Card and enter it in the appropriate field.
- Circle the medication name, the date, and the amount you paid for XR or on your original pharmacy receipt.
- Scan or take a picture of your pharmacy receipt, ensuring that it is clear and legible.
- Check the certification box to confirm that you meet the terms and conditions as well as the eligibility requirements.
- Email the completed rebate form along with your scanned pharmacy receipt to xeljanzsupport@trialcard.com.
- To finalize, you can save changes to your form, download it for your records, print it, or share it as needed.
Complete your Rebate Form online today to ensure you receive your reimbursement promptly.
The Recovery Rebate Credits (Economic Impact Payments/Stimulus Checks) for 2020 and 2021. Claim your first, second, or third stimulus check! You can claim the stimulus payments as a tax credit and get the money as part of your tax refund. The stimulus checks are a federal tax credit, known as the Recovery Rebate Credit ...