Transcription of Injectafer Savings Program Check Fax Request Form
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Injectafer Savings Program Check Fax Request Form
Please Check one box: Patient ( Check will be made payable to Patient Name and mailed to Patient Mailing Address) Practice/Physician ( Check will be made payable to Practice Name and mailed to Practice Mailing Address)Patient Name: Patient Mailing Address: Patient Telephone Number: - - Date of Service: - - Injectafer Card ID: INJ Amount Requested: $ Doctor Name: Doctor Telephone Number: - - This section should only be completed if the Check is being mailed to a Physician or Practice. Physician or Practice Name: Mailing Address: Signature: Date: - - Terms and Conditions: 1.
PP -US IN 0382 10/17 Injectafer Savings Program Check Fax Request Form Please fax the Explanation of Benefits (EOB) form from the …
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