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Click ‘Get Form’ to open the prescription reimbursement claim form in the editor.
Begin by filling out the Card Holder/Patient Information section. Ensure you provide your Identification Number, Group Number, and personal details such as Last Name, First Name, Address, and Date of Birth. This information is crucial for processing your claim.
In the Pharmacy Information section, include the Pharmacy Name and Address. If applicable, check any relevant boxes regarding insurance coverage or reasons for filing a claim.
Attach all original pharmacy receipts as required. Ensure that each receipt includes necessary details like Patient Name, Prescription Number, and Total Charge. This will help avoid delays in processing your claim.
Finally, review all entered information for accuracy before signing the form. Once completed, mail it along with receipts to the specified 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)

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cvs prescription reimbursement form

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