Gateway health form 2026

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This document provides instructions for completing a claim form for reimbursement of prescription drug expenses under the Gateway Health Medicare AssuredSM plan. It includes sections for member and pharmacy information, guidelines for filling out the form, and important notes regarding claims submission and eligibility.

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Click ‘Get Form’ to open the gateway health form in the editor.
In Part 1, enter your Member ID, Name, Date of Birth, Address, and Telephone Number. Ensure all information is accurate for smooth processing.
Sign the form to certify that the medication was received and that you are eligible for drug benefits.
Move to Part 2 for Pharmacy Information. Enter the pharmacy name, address, and telephone number where prescriptions were filled.
For each prescription (RX1 to RX4), fill in the Date of Service, Prescription Number, NDC Number, Amount Paid, Quantity, Days Supply, and Prescriber Name as indicated on your pharmacy receipt.
Review all entries for accuracy before submitting. Remember not to include cash register receipts.

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