Claim Submission Form
Group Name
*
Subscriber Name
*
Subscriber ID number
*
Patient name
*
First Name
Last Name
Address where reimbursement should be sent (reimbursement check will be made out to the subscriber, regardless of the address you supply).
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email address
*
example@example.com
Phone Number (Only used if there is a question about your claim).
*
Please enter a valid phone number.
Please upload the prescription receipt for which you are requesting reimbursement.
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