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14423-0610 STANDARD Prescription Reimbursement Claim Form Important-2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the Card Holder/Patient Information section. Ensure you include the Identification Number, Group No./Name, and full names along with the address details.
- Complete the Patient Information fields, including Date of Birth and Relationship to Primary member. If there are multiple patients, use a separate claim form for each.
- In the Other Insurance Information section, indicate if any medicines are related to an on-the-job injury and provide details about other insurance coverage if applicable.
- Gather all original receipts as required for submission. Ensure they contain necessary information such as Patient Name, Date of Fill, Total Charge, and more.
- Follow the Mailing Instructions carefully based on your RXBIN number to ensure your claim is sent to the correct address.
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