Download and complete either the Word or PDF version of the:
- Approved supplier manual payment reconciliation form
- Approved supplier manual payment reconciliation form.
If you close your claim electronically, you do not need to use this form.
We require you to keep a copy of the completed form that you submit to us for your records.
We will only accept typed prescription order forms. We will return handwritten, incomplete or poor quality forms to the prescriber.
To fill in this form digitally you will need a computer and Adobe Acrobat Reader, or a similar program. You can download Adobe Acrobat Reader for free. If you can’t complete the form digitally, you can print it, complete it by hand and return it to us following the instructions on the form.
If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please contact us. We can help you access, complete and submit them.