This form should be used ONLY if you are submitting claims for secondary prescription coverage. Note: Your request will be reviewed, and reimbursement is not guaranteed.
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Pharmacy Prescription Reimbursement Secondary Claim Form
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Authorization for Release of Health Information – Specific Request
Like the “standing” version of this form, you can choose someone you trust to have “one-time” access to a specific part of your personal health information. Do not worry, if you do not fill out this form, Priority Partners will continue to keep your health information protected and private.