Get Rebate Form

Filling out the Rebate Form online is a straightforward process that can help you receive your savings for ® treatments. This guide provides a step-by-step overview to ensure you complete the form accurately and efficiently.

Follow the steps to complete the Rebate Form online.

1. Click the ‘Get Form’ button to download the Rebate Form and open it in your preferred editor.
2. Provide your personal information in the designated fields. This includes your full name, address, city, state, ZIP code, and email address.
3. Enter your date of birth in the required format (MM/DD/YYYY). This information helps verify your eligibility for the rebate.
4. Input the details of your pharmacy including the name, address, and phone number. This information should match the pharmacy invoice you will attach to the form.
5. List each prescription number, fill date, drug name, strength, and NDC # as required. These details are critical to process your rebate.
6. Include information about the quantity, price, and/or co-pay amount you have paid for ®. Ensure accuracy to avoid delays.
7. Fill in your ® ID# and group number as directed. This is necessary for verifying your participation in the savings program.
8. Review all information for completeness and accuracy. Incorrect information may hinder the processing of your rebate.
9. Once the form is fully completed, you can save changes, download a copy for your records,print, or share the form as necessary.

Start filling out your Rebate Form online today to ensure you receive your savings!