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Request for Reimbursement

                                  

 

Proof of Expenditure (POE) form is for approved PAN enrollees to obtain reimbursement for approved PAN deductible, co-payment, and co-insurance expenses.  

 

You do not need a POE form if your provider or pharmacy submits a claim on your behalf to PAN.

 

Expenses are not eligible for reimbursement if they are incurred:

       After <<expense end date>>; or,

       After your grant maximum has been met.

 

Instructions:

 

1.       Complete, sign, and date the POE form. The patient or an individual completing the form on the patient’s behalf may sign the form.

 

2.       Attach expense documentation. Examples include invoices, EOBs, prescription labels, receipts, or statements. 

 

3.       Mail or fax the form and all required documentation to: 

                Fax:                  (844) 726-4728

                Mailing Address:  Patient Access Network Foundation, PO Box 231, Mt. Clemens, MI 48046

 

POE forms are reviewed and processed upon receipt. Payment will be issued within 10 business day of receipt of a complete claim.

 

If you have any questions, please contact PAN at (866) 316-PANF (7263) Monday through Friday, 9 a.m. until 5 p.m. EST.

                                           
     Click here to download the form.