Mra Pay Me Back Claim Form - Fill Online, Printable, Fillable 2026

1. Click ‘Get Form’ to open the Mra Pay Me Back Claim Form in our platform's editor.
2. Begin by filling out the Enrollee Information section. Enter your last name, first name, street address, apartment number (if applicable), city, state, zip code, and email address in all capital letters as instructed.
3. Next, provide Patient Information. Fill in the patient's name, date of birth, sex, and relationship to the enrollee. If applicable, indicate if the patient has additional health insurance coverage and include necessary documentation.
4. In the Prescription Information section, enter details such as pharmacy name and phone number. Include the date of fill and prescription number for each medication. Ensure you attach itemized receipts from the pharmacy.
5. Complete the Enrollee Certification by signing and dating the form to confirm that all information is accurate.

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