( for extended-release ... - OPUS Health 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by completing the Patient Information Section at the bottom of the form. Fill in your last name, first name, Rx Group number, Rx ID number, street address, city, state, zip code, phone number, and email.
3. Gather and attach the required documents: a copy of the co-pay card offer, an Explanation of Benefits (EOB) form for insured patients, an itemized cash receipt for self-pay patients, a Payer-Specific Insurance Billing Form (CMS-1500), and proof of payment for the injection.
4. Review all filled sections and attached documents to ensure accuracy before mailing.
5. Mail the completed form along with all requested documentation to OPUS Health at the specified address.

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