14423-0610 STANDARD Prescription Reimbursement Claim Form Important-2026

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The document is a Prescription Reimbursement Claim Form that outlines the process for submitting claims for prescription reimbursements. It includes instructions for completing the form, necessary patient and cardholder information, submission requirements, and mailing instructions based on different RXBIN numbers. The document emphasizes the importance of including original receipts and provides a warning about fraudulent claims.

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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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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (137 Votes)
2014	4.3 Satisfied (61 Votes)
2011	4.3 Satisfied (46 Votes)
2010	4.2 Satisfied (49 Votes)
2008	4 Satisfied (55 Votes)
2008	4.9 Satisfied (43 Votes)