[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288329-105":53,"doc-detail-288329-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","reimbursement-request-form-41524","Reimbursement Request Form - 4.15.24","","This Reimbursement Request Form is a standardized document provided by Sav-Rx to facilitate the submission of out-of-pocket prescription medication costs. The document requires detailed participant information, including cardholder name, ID, and contact details, alongside specific prescription data such as the date filled, total out-of-pocket expenses, and whether a coupon was utilized. It serves as an essential tool for members to request financial reimbursement for medications that did not utilize the standard benefit card. Furthermore, the form mandates the attachment of valid receipts that contain comprehensive information, including the member's name, date of service, drug name, quantity dispensed, amount paid, NDC, and prescription number. By signing this document, the participant formally attests to the accuracy of the provided information and acknowledges the policy that reimbursement is subject to clinical review and benefit structure adherence, offering no absolute guarantee of payment for non-compliant claims.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":21,"@type":70,"position":76},"https://docshare.wps.com/template/invoices/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/reimbursement-request-form-41524/288329/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/reimbursement-request-form-41524/288329.png","ImageObject",442,249,{"name":88,"@type":89},"Clementine","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-18","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What specific information must be included on the receipts submitted with this form?","Question",{"text":108,"@type":109},"Receipts must include the member name, date of service, drug name, quantity dispensed, amount patient paid, drug NDC, and the prescription number.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Where should this form be sent once completed?",{"text":113,"@type":109},"The form should be sent to the attention of the “Reimbursement Department” when mailing it to Sav-Rx.",{"name":115,"@type":106,"acceptedAnswer":116},"What does the cardholder's signature on this form attest to?",{"text":117,"@type":109},"The signature confirms that all provided information is true to the best of the individual's knowledge and acknowledges that reimbursement is not guaranteed for medications that may have required prior authorization.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288329,1789633369,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":20,"category_name":21,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":9,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":4},1374391974564,"https://ap-avatar.wpscdn.com/avatar/14000253aa45c000a9e?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779874745381141002","224 North Park Ave • Fremont, NE 68025 Phone: (402) 753-2800 • Fax: (402) 753-2890  \nReimbursement Request Form  \nNote: Please send to the attention of the “Reimbursement Department” when mailing this form to Sav-Rx.  \nParticipant Information  \n\n| Cardholder Name (See ID Card): |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Cardholder ID (See ID Card): |  | Relation to Cardholder: ☐ Self ☐ Dependent |  |  |\n| Participant Name: |  |  | Date of Birth: |  |\n| Phone Number: |  |  | Email Address: |  |\n| Address: |  |  |  |  |\n| City: | State: |  | Zip Code: |  |\n| Prescription Information |  |  |  |  |\n| Number of Prescriptions Submitted: |  |  | Date Prescription(s) Filled: |  |\n| Out-of-Pocket Total: |  |  | (For multiple prescriptions please use a range from first to last)\u003Cbr>Coupon Used At Time Of Processing: ☐ Yes ☐ No |  |\n| Reimbursement Information |  |  |  |  |\n| In the space below, please provide the reason for not utilizing the Sav-Rx card/ submitting this reimbursement request: |  |  |  |  |\n| |  |  |  |  |\n| Please provide receipts for prescriptions along with this form.\u003Cbr>Please note any receipts submitted to Sav-Rx for reimbursement must include the following |  |  |  |  |\n| • Member Name\u003Cbr>• Date of Service\u003Cbr>• Drug Name | • Quantity Dispensed\u003Cbr>• Amount Patient Paid\u003Cbr>• Drug NDC |  |  | • Prescription Number |\n\nCardholder Signature Date  \nBy signing the above, you attest that all information is true to the best of your abilities in seeking reimbursement for medications paid out of pocket and/ or that did not adhere to the benefit structure – resulting in a larger amount paid. You also acknowledge that there is no guarantee of reimbursement for medications that may have required a prior authorization or clinical review prior to dispensing the medication(s) .","cbCaih5hd13gGL94","https://ap.wps.com/l/cbCaih5hd13gGL94","pdf",136961,"English","# Participant Information\n# Prescription Information\n# Reimbursement Information\n## Submission Requirements","[{\"question\":\"What specific information must be included on the receipts submitted with this form?\",\"answer\":\"Receipts must include the member name, date of service, drug name, quantity dispensed, amount patient paid, drug NDC, and the prescription number.\"},{\"question\":\"Where should this form be sent once completed?\",\"answer\":\"The form should be sent to the attention of the “Reimbursement Department” when mailing it to Sav-Rx.\"},{\"question\":\"What does the cardholder's signature on this form attest to?\",\"answer\":\"The signature confirms that all provided information is true to the best of the individual's knowledge and acknowledges that reimbursement is not guaranteed for medications that may have required prior authorization.\"}]","Reimbursement Request Form - 4.15.24 | PDF"]