Follow the steps to successfully complete your reimbursement form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Fill in your personal information in the 'Patient Information' section. Include your first name, middle name (if applicable), last name, address, city, state, zip code, phone number, email, date of birth, and gender. Ensure all details are accurate.
3. In the 'Reimbursement Process' section, confirm that you have included a copy of the DUPIXENT prescription label. This must be a clear prescription receipt from your pharmacy that displays the pharmacy's name and address, dosing information, and days supply.
4. Complete the required information regarding your copay card in the provided boxes. At this stage, also ensure you provide the member ID, group number, BIN, PCN, and ID as requested.
5. Sign and date the form as indicated in the 'Patient signature and certification' section. This signature certifies that the information you have provided is accurate and that the expenses were actually incurred.
6. Review your completed form to ensure all fields are filled out completely and accurately. Ensure you have included any necessary attachments, as forms submitted without these will not be eligible for reimbursement.
7. Once all information is complete, you can choose to save your changes, download the form, print it, or share it as needed. Make sure to submit the signed form and attachments via mail or fax to the provided address or fax number.

Get started on your reimbursement today by filling out the form online.