Clients Check Inquiry

CHECK INQUIRY

Prime Therapeutics requires that a check be outstanding for two weeks before a check inquiry is submitted.

To submit a check inquiry, please complete the form below. A replacement check will be issued to you in 2 to 3 weeks, provided that the original check has not been cashed.

	* required field
CLIENT CONTACT Who is making the request?	Name * Phone * Email

DESCRIPTION OF ISSUE	Lost - Same Address Lost - Address Changed Other

CHECK INFORMATION	Date Issued (Approximate) * Amount (Approximate) * Check Number (If Known) Health Plan * Specify "Other" Health Plan

MEMBER INFORMATION	Member Name * ID/Contract # * Address * City, State, Zip * Is this a new Address? Yes No

SPECIAL INSTRUCTIONS