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Get Proact Claims Form

Attach Pharmacy Receipt for each claim submitted Review, sign, and send to: ProAct Pharmacy Services, Inc 1230 US HWY 11 Gouverneur, NY 13642 Attn: DMR Dept. IMPORTANT: MISSING INFORMATION MAY CAUSE A DELAY IN PAYMENT. PART A Employee/Patient information Employee s Name: Last First Member # (on ID Car Patient s Name: Last First Relationship to Employee Employee s Street Address City Group ID#(on Card) Employer/Carrie State Employee s Daytime Phone # ( ) Zip Code Ple.

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