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Downloadable Forms

Check Request Form

Complete this form when you are seeking reimbursement after paying the provider for your treatment. The instructions for using the program with these providers are included on the form.

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We are open from 9 a.m.–8 p.m. ET, Monday through Friday, except for the following holidays:

  • New Year's Day
  • Memorial Day
  • Independence Day
  • Labor Day
  • Thanksgiving Holiday (Thursday and Friday)
  • Christmas Holiday

Questions about this program?

Call (844) HEM-COPAY (844-436-2672)
9 a.m.–8 p.m. ET, Monday through Friday (except major holidays)
 
For questions about HEMLIBRA, please call (866) HEMLIBRA (866-436-5427).

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Fax (855) HEM-COPAY  (855-436-2672)

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