Find the Form You Need Here

Streamlining our processes and simplifying our system is always top of mind at VerusRx. We’ve included several of our most requested forms here (at right). If you are unable to find the form you need here, just call our Customer Service team – at any time of day or night – at 1-800-838-0007.

Member Reimbursement Form

To ensure timely processing of your claim, complete the reimbursement form making sure to include: the original pharmacy receipt for each drug (not the register receipt) with the date the prescription was filled; prescription number (Rx#); name and strength of drug; prescribing physician’s name or ID number; pharmacy name and address; quantity and days’ supply; National Drug Code (NDC) number; compound ingredient information (if applicable); and amount paid. 

More Forms You May Need

  • Prescription Claim Form - Direct Member Reimbursement

    Click to Download

  • Authorization to Use and Disclose Health Information

    Click to Download

  • Precertification Request Form - Prescription Drugs

    Click to Download

  • Mail Order Pharmacy Enrollment Form

    Click to Download