Direct member reimbursement form 2026

1. Click ‘Get Form’ to open the direct member reimbursement form in the editor.
2. 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.
3. Provide your mailing address, prescribing physician's name, and their DEA or NPI number along with their telephone number.
4. In the Reason For Request section, clearly state why you are seeking reimbursement.
5. If applicable, complete the Coordination of Benefits section by providing details from your primary insurance regarding any payments made for the prescription.
6. For vaccine claims, check all relevant boxes indicating where the vaccine was filled and administered.
7. If submitting a compound prescription, list each ingredient's valid 11-digit NDC number along with its quantity and total charge paid.
8. 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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