Pharmacy COVID-19 Reimbursement Claim Form
Submit your pharmacy's reimbursement claim for COVID-19-related services or supplies. Please complete all fields accurately to ensure timely processing.
Pharmacy Name
*
Pharmacy NPI or Store ID
*
Contact Person Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Claim Submission
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
COVID-19 Service or Supply Type
*
Please Select
Vaccination
Testing
Therapeutics
Personal Protective Equipment (PPE)
Other
Patient Initials (do not enter full name)
*
Date of Service/Supply Provided
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Amount Claimed (USD)
*
Brief Description of Service/Supply
*
Upload Supporting Document(s)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Claim
Should be Empty: