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Injectafer Savings Program Eligibility Attestation Form

Injectafer Savings Program Eligibility Attestation Form

injectafercopay.com

PP-US-IN-0381 10/17 Injectafer Savings Program Eligibility Attestation Form I, _____ (Print Name), certify that on _____&_____

  Programs, Form, Eligibility, Savings, Attestation, Injectafer, Injectafer savings program eligibility attestation form

Injectafer Savings Program Check Fax Request Form

Injectafer Savings Program Check Fax Request Form

injectafercopay.com

PP -US IN 0382 10/17 Injectafer Savings Program Check Fax Request Form Please fax the Explanation of Benefits (EOB) form from the patient’s insurance company to (888) 257- 4673. Please ensure that the EOB provided includes the Name of the Insurance Company, Date of

  Programs, Form, Request, Savings, Check, Injectafer, Injectafer savings program check fax request form

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Injectafer Savings Program Eligibility Attestation Form, Injectafer Savings Program Check Fax Request Form, Form