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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
PHARMACY 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
 
PHARMACY INFORMATION Pharmacy Name *
NABP# *
Address *
City, State, Zip *
Is this a new Address? Yes     No

 
SPECIAL INSTRUCTIONS
   


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