You must download our forms to fill them in. We have help available if you use assistive technology or if you need a translator or interpreter. Find out how to use our forms.
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.