Reimbursement & Other Forms

• HIPAA Authorization Form
• Appointment of Authorized Representative Form
  
• Direct Member Reimbursement (DMR) Form
• OTC At Home COVID 19 Test Reimbursement Form

Members who have paid out of pocket for prescriptions during eligible periods should complete the Direct Member Reimbursement form to request reimbursement. Please send completed HIPAA and DMR forms by fax to 1-866-834-4614.

or by mail to:

WithMe Health
ATTN: Member Services
P.O. Box 1446
Hudson, OH 44236