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Completing the co-pay savings program patient mail-in form for is a straightforward process designed to facilitate reimbursement for your medication. This guide provides step-by-step instructions to ensure that you fill out the form correctly and submit the necessary documentation.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred digital editor.
2. Fill in the Patient Information Section located at the bottom of the form, which includes your last name, first name, Rx group number, Rx ID number, street address, city, state, zip code, phone number, and email.
3. Prepare your documentation for submission by gathering the required items, which include: a copy of the co-pay card offer, an Explanation of Benefits (EOB) Form for insured patients, a patient’s itemized cash receipt for self-pay patients, a Payer-Specific Insurance Billing Form (CMS-1500), and an in-office receipt for the paid injection as proof of payment.
4. Once the Patient Information Section is completed and all required documents are gathered, attach these documents to the Patient Mail-in Form.
5. Mail the completed Patient Mail-in Form along with the attached documentation to: OPUS Health, 1324 Motor Parkway, Suite 105, Hauppauge, NY 11749, ATTN: Card Processing Department.
6. It is advisable to keep a copy of the submitted form and documentation for your records and note that the claim processing may take 2-3 weeks.

Complete your co-pay savings form online today to streamline your reimbursement process.