Prescription Reimbursement Form

Use this form to request reimbursement for eligible prescriptions you paid for out of pocket or out of network. Fill it out below, print it, attach a copy of your receipt, and mail it to the address shown. Your request is processed in approximately 4–6 weeks.

Private by design. Everything you type stays on your device — this form does not send or save any of your information. You print the completed form and mail it yourself.

Member Information

Patient's Name (Last, First, MI)

Patient's DOB

Patient's Sex

Patient's Email

Patient's Phone

Insured's Name (Last, First, MI)

Patient's Relationship to Insured

ID Number (on the front of your card)

Account/Plan Number (on the front of your card)

Prescription Information

Date Filled

RX Number

Quantity Dispensed

Day Supply

Drug Name

Drug Strength

Dosage Type(optional)

Manufacturer(optional)

NDC#(optional)

Pharmacy Name

Pharmacy NPI(optional)

Pharmacy NABP(optional)

Amount Paid (Receipt Required)

Pharmacy Address

Prescriber Name (Last, First)

Prescriber NPI(optional)

Prescriber Address (City, State, Zip)

Acknowledgement

By signing below, I am stating that the information above is correct. Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete, or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties.

Signature (sign after printing)

Date

Phone

Return Address

Provide a current mailing address. A copy of the receipt must be included.

First Name

Last Name

Street Address

City, State, Zip

Mail the completed form and a copy of your receipt to:

ATTN: RxSense DMR Team
3001 PGA Boulevard, Suite 202
Palm Beach Gardens, FL 33410