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Direct member reimbursement form 2026
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- Click ‘Get Form’ to open the direct member reimbursement form in the editor.
- Begin by filling out the Patient Information section. Enter your Health Plan/Insurance Name, Group Employer/Name, and your personal details including your name, birth date, and I.D. number.
- Provide your mailing address, prescribing physician's name, and their DEA or NPI number along with their telephone number.
- In the Reason For Request section, clearly state why you are seeking reimbursement.
- If applicable, complete the Coordination of Benefits section by providing details from your primary insurance regarding any payments made for the prescription.
- For vaccine claims, check all relevant boxes indicating where the vaccine was filled and administered.
- If submitting a compound prescription, list each ingredient's valid 11-digit NDC number along with its quantity and total charge paid.
- Finally, sign and date the form at the bottom to certify that all information is accurate before submitting it along with your receipts.
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direct member reimbursement form
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