Get Copay Savings Program Reimbursement Form

The Copay Savings Program Reimbursement Form is designed to help individuals receive reimbursement for their out-of-pocket costs for ®. This guide provides clear, step-by-step instructions on how to complete the form online, ensuring a smooth and straightforward process for users.

Follow the steps to effectively complete the reimbursement form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Complete the practice billing information section. Fill in all required fields including the practice name, NPI, tax ID, address, city, state, contact number, email address, physician's first and last name, and physician NPI.
3. Provide the patient’s information in the designated section. Fill in all mandatory fields such as first name, middle initial, last name, address, gender, city, state, phone number, email address, ® Copay Savings Program Group number, zip code, and date of birth.
4. In the patient certification and consent section, ensure the patient or a parent/guardian signs to attest that the information provided is accurate and that the expenses have not been reimbursed by federal or state programs.
5. Select the appropriate payment option by indicating whether assistance should be remitted to the patient or to the practice/physician, ensuring to sign and date the assignment of benefits.
6. Attach the required documents based on the patient’s payment method. For insured patients, include a copy of the Explanation of Benefits (EOB), and for cash-paying patients, attach a receipt showing the amount paid for ®.
7. Submit the completed form along with the attachments via mail, fax, or email. Ensure all documents are sent to the correct addresses provided in the form.
8. After submission, allow up to 10 business days for processing if submitted via fax or email, or up to 15 business days for mailed submissions.

Complete and submit your Copay Savings Program Reimbursement Form online today for a streamlined experience.