Follow the steps to successfully complete the RxER claim form online.

1. Press the 'Get Form' button to acquire the RxER Claim Form ReV 2 and open it for editing.
2. Fill out all necessary fields, starting with the date filed. Ensure you mark the appropriate type of claim, either Out Patient or Member Financial Assistance.
3. Enter the patient’s name, including given name, middle initial, and last name. Proceed to add the RxER Member ID number.
4. If the patient is a minor, provide the guardian's name, including their given name, middle initial, and last name.
5. Complete the home address and contact number fields accurately. Don’t forget to include the hospital name.
6. Input the date of medical treatment or confinement. This date is crucial for processing the claim.
7. Select the manner of payment by marking the appropriate checkbox for whether the check should be payable to the patient or the guardian.
8. State the total amount of claim and specify other details if applicable. Ensure this amount is consistent with the receipts and invoices.
9. Have the attending physician complete their section, including chief complaints, laboratory tests requested, final diagnosis, and procedures performed.
10. Confirm that the attending physician signs and dates this section, along with providing their specialization and license number.
11. Choose the preferred method for the release of the check and/or memo, marking the appropriate box and providing any necessary mailing address.
12. Sign the consent section, acknowledging the collection and processing of your information. If necessary, an authorized representative may sign.
13. Review all information for accuracy before finalizing the form.
14. Once completed, save changes, then download, print, or share the form as needed.

Complete your documents online to ensure a smooth reimbursement process.