Check Copy Request

Complete this form to receive a copy of a check. You will be charged a $25 processing fee per check. Please allow up to 2 weeks to receive the copy.

All fields are required unless otherwise noted.

Seven-Digit NCPDP Number:
Contact Name:
Three-Digit Chain ID:
Check Number:
Check Amount:
Check Date:
Three-Digit Division Code (DIV)*:
Phone Number:
Fax Number (optional):
E-Mail (optional):
Comments:
*DPS claims only