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  • Proact Claims Form

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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Make the most of our extensive online document editor while preparing your paperwork. Complete the Proact Claims Form, emphasize on the most significant details, and effortlessly make any other essential modifications to its content.

Preparing documentation electronically is not only time-saving but also comes with an opportunity to modify the sample in accordance with your requirements. If you’re about to work on Proact Claims Form, consider completing it with our extensive online editing solutions. Whether you make an error or enter the requested details into the wrong area, you can easily make changes to the form without the need to restart it from the beginning as during manual fill-out. In addition to that, you can point out the crucial data in your paperwork by highlighting particular pieces of content with colors, underlining them, or circling them.

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You or your pharmacist should call ProAct's 24/7/365 Help Desk (1-877-635-9545) immediately for a resolution. Your physician can start the prior authorization review process by visiting proactrx.promptpa.com to obtain medication specific request forms.

Prior Authorization Form Navigator If you do not have the bin number please contact 1-877-635-9545.

ProAct, Inc. is a fully integrated pharmacy benefit management (PBM) company with a mail order pharmacy. At ProAct, we strive to produce innovative, affordable and flexible prescription drug benefit solutions for the client by combining industry-leading client service with the latest in PBM technology.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232