Get Proact Claims Form

Filling out the Proact Claims Form is an essential step for users seeking reimbursement for their pharmacy expenses. This guide will provide you with clear and comprehensive instructions to help you navigate the online form efficiently.

Follow the steps to complete your reimbursement form accurately.

1. Click ‘Get Form’ button to obtain the Proact Claims Form and access it in your preferred format.
2. In Part A, fill in your employee and patient information. Provide the last name, first name, member number (as indicated on your ID card), patient's last and first name, their relationship to you, your street address, city, state, zip code, and daytime phone number.
3. Clearly explain the reason the patient paid the full amount out of pocket in the designated area.
4. In Part B, enter prescription information including days supply, Rx number, Rx date, NDC number, quantity, amount paid, and copay.
5. Review all entered information to ensure accuracy, as missing information may delay payment.
6. Sign and date the authorization statement to certify that the information is correct and authorize necessary parties to release any required information.
7. Indicate whether the form is approved for processing by circling 'YES' or 'NO'.
8. Ensure all receipts from the pharmacy are attached to the claim and send the completed form to ProAct Pharmacy Services at the provided address.
9. Once submitted, you can keep a copy for your records. You may also download, print, or share the completed form as necessary.

Start filling out your Proact Claims Form online today for a smoother reimbursement process.