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. Complete this form to receive a copy of a remittance form. Pharmacy remittance reprints may be subject to a processing fee. For independent pharmacies and Diversified Pharmaceutical Services, Inc., claims, checks and remittances are mailed separately, within 2 weeks of each other. Generally, the check is mailed first.

All fields are required unless otherwise noted.

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