Get Md Healthwell Foundation Reimbursement Request Form 2019-2025

Filling out the MD HealthWell Foundation Reimbursement Request Form online can be a straightforward process if you follow these steps carefully. This guide will provide clear instructions to help you complete each section of the form accurately.

Follow the steps to fill out the MD HealthWell Foundation Reimbursement Request Form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Enter the HealthWell identification number in the designated field. This number is essential for processing your reimbursement request.
3. Provide the patient's full name, including the first name, middle initial, and last name in the corresponding field.
4. Indicate the person's or entity's name that will receive the reimbursement by checking the appropriate box (Clinic, Hospital, Patient/Guardian, Pharmacy, or Physician's Office).
5. Record the patient's birth date accurately in the designated area to confirm their identity.
6. In the section labeled 'Make Check Payable to,' write the name of the person, facility, or organization that should receive the reimbursement.
7. Provide the complete address for payment, including street, city, state, and zip code, to ensure accurate delivery.
8. Enter the telephone number for contact purposes.
9. Fill out the email address for electronic communication regarding the reimbursement request.
10. Input the date(s) of service provided under the relevant section.
11. List the name of the medication(s) or the J-Code associated with the treatment in the specified field.
12. Provide the diagnosis and the corresponding ICD-10 code to clarify the medical condition being treated.
13. Record the total amount billed to the insurer for the services rendered.
14. Specify the amount that the insurer has allowed for the reimbursement.
15. Enter the patient's copay amount required for the service.
16. Include any patient reference information that you want printed on the reimbursement check, ensuring it does not exceed 20 characters.
17. Attach required documentation with your request, including the explanation of benefits, pharmacy receipts, or proof of payment as necessary.
18. Sign the form in the designated area to confirm that the information provided is complete and accurate.
19. Date the form. If left undated, HealthWell will consider the submission date as the processing date.
20. Save your changes, download, print, or share the completed form as required.

Complete your MD HealthWell Foundation Reimbursement Request Form online today!