RxAmerica

Complete this form on your screen. Up to 5 prescriptions can be included on one form.
Verify that all entered information is correct, then click the "Validate" button.
Press the 'Continue to Print' button, and print the page that displays.
Sign the printed form and mail to:
RxAmerica c/o Data Entry
221 N. Charles Lindbergh Dr.
SLC, UT 84116
Attach all prescription receipts to the back of the printed form. Receipts must contain all of the following information or they will not be accepted: Rx number, date filled, physician, drug name with NDC number, drug strength, quantity, days supply, and amount paid.
Address the envelope, affix proper postage, and mail to the address on the printed form.
Thank You!

Employee (Member) Information: (Individual on the RxAmerica ID card.)
Employee's Full Name:
Member ID:
Mailing Address:
City:
State:
Zip:
Employer's Name:
Patient Information:
Patient's Full Name:
Date of Birth:	mm/dd/yyyy
Gender:
Relationship to Employee:
Prescription Information:
Are these reimbursement(s) for double coverage? Yes No
**** Prescription #1 ****
Rx Number:
Date Rx Filled:	mm/dd/yyyy
Physician's Name:
Physician's DEA Number:
Drug Name:
Drug NDC Number:
Drug Strength:
Rx Quantity:
Days Supply:
Amount Paid:
**** Prescription #2 ****
Rx Number:
Date Rx Filled:	mm/dd/yyyy
Physician's Name:
Physician's DEA Number:
Drug Name:
Drug NDC Number:
Drug Strength:
Rx Quantity:
Days Supply:
Amount Paid:
**** Prescription #3 ****
Rx Number:
Date Rx Filled:	mm/dd/yyyy
Physician's Name:
Physician's DEA Number:
Drug Name:
Drug NDC Number:
Drug Strength:
Rx Quantity:
Days Supply:
Amount Paid:
**** Prescription #4 ****
Rx Number:
Date Rx Filled:	mm/dd/yyyy
Physician's Name:
Physician's DEA Number:
Drug Name:
Drug NDC Number:
Drug Strength:
Rx Quantity:
Days Supply:
Amount Paid:
**** Prescription #5 ****
Rx Number:
Date Rx Filled:	mm/dd/yyyy
Physician's Name:
Physician's DEA Number:
Drug Name:
Drug NDC Number:
Drug Strength:
Rx Quantity:
Days Supply:
Amount Paid: