Reimbursement & Other Forms

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
400 S El Camino Real Suite 1150
San Mateo, CA 94402