Full Name of Member (e.g., Jane Smith)
* must provide value
Member ID
* must provide value
Member Date of Birth (DOB)
* must provide value
Today M-D-Y
Legal Authorized Representative Full Name if Member is NOT self-submitting (e.g., Michael Smith) - The name must accurately reflect the individual who submitted the initial payment/check/transaction (if it is not the member).
* must provide value
Legal Authorized Representative Address
* must provide value
(Street Number, Street Address, City, State, Zip Code)
Retail Pharmacy where transaction(s) took place.
* must provide value
(Pharmacy Name & Address)
Retail Pharmacy Phone Number
* must provide value
Drug Name to be Reimbursed
* must provide value
If more than one drug, separate name as follows (e.g., Drug A, Drug B, Drug C)
Cost ($USD) Requesting to be Reimbursed
* must provide value
How many medication leaflets would you like to upload?
* must provide value
1 2 3 4 5
Medication Leaflet #1 (Non-anonymous question)
* must provide value
File number limit: 1Single file size limit: 1GBAllowed file types: Word, Excel, PPT, PDF, Image, Video, Audio
Medication Leaflet #2 (Non-anonymous question)
* must provide value
File number limit: 1Single file size limit: 1GBAllowed file types: Word, Excel, PPT, PDF, Image, Video, Audio
Medication Leaflet #3 (Non-anonymous question)
* must provide value
File number limit: 1Single file size limit: 1GBAllowed file types: Word, Excel, PPT, PDF, Image, Video, Audio
Medication Leaflet #4 (Non-anonymous question)
* must provide value
File number limit: 1Single file size limit: 1GBAllowed file types: Word, Excel, PPT, PDF, Image, Video, Audio
Medication Leaflet #5 (Non-anonymous question)
* must provide value
File number limit: 1Single file size limit: 1GBAllowed file types: Word, Excel, PPT, PDF, Image, Video, Audio
How many medication receipts would you like to upload?
* must provide value
1 2 3 4 5
Medication Receipt #1 (Non-anonymous question)
* must provide value
File number limit: 10Single file size limit: 100MBAllowed file types: Word, Excel, PPT, PDF, Image, Video, Audio
Medication Receipt #2 (Non-anonymous question)
* must provide value
File number limit: 10Single file size limit: 100MBAllowed file types: Word, Excel, PPT, PDF, Image, Video, Audio
Medication Receipt #3 (Non-anonymous question)
* must provide value
File number limit: 10Single file size limit: 100MBAllowed file types: Word, Excel, PPT, PDF, Image, Video, Audio
Medication Receipt #4 (Non-anonymous question)
* must provide value
File number limit: 10Single file size limit: 100MBAllowed file types: Word, Excel, PPT, PDF, Image, Video, Audio
Medication Receipt #5 (Non-anonymous question)
* must provide value
File number limit: 10Single file size limit: 100MBAllowed file types: Word, Excel, PPT, PDF, Image, Video, Audio
Why did you pay out of pocket?
* must provide value
Out of state Emergency Room (ER) visit Insurance (COB) issue Eligibility issue Other
Explanation on why a DMR is needed (at least 2 sentences). If a sufficient explanation is not provided, a DMR request is subject for rejection.
* must provide value