You don’t need to use this form, or pay a fee, if you claim online.
Please keep a copy of your completed forms for your records.
Download and complete the Manual prescription processing fee for pharmaceutical benefits form.
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.