Get Direct Member Reimbursement Form - Wayne State University

This guide provides clear and supportive instructions for users on how to complete the Direct Member Reimbursement Form online. By following these steps, users can ensure that their reimbursement requests are submitted accurately and efficiently.

Follow the steps to fill out the form correctly and submit your request.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the insured member information section. Provide your Member ID, Employer name, and indicate to whom the check should be made payable. Enter your full name and group number as displayed on your card.
3. Move on to the patient information section. Fill out the patient's name, date of birth, and relationship to the insured member. Indicate the patient's sex by selecting the appropriate option.
4. For the prescription information, specify if there is a secondary claim or coordination of benefits by checking yes or no. Be sure to gather and attach all necessary pharmacy receipts that include essential details such as the prescription number, quantity dispensed, NDC number, fill date, day supply, and amount paid.
5. Once all fields are completed and verified, you can save your changes, download the completed form, or print it for submission.
6. Finally, submit the form by mailing it to PharmaCare as indicated or by faxing it to the provided number. If you have any questions regarding the reimbursement process, contact Customer Service at the provided phone number.

Complete your Direct Member Reimbursement Form online today to ensure your reimbursement request is processed efficiently.