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CHECK INQUIRY

Member Services 1-888-642-0447

Prime Therapeutics requires that a check be outstanding for 30 days 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