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Downloadable Form for a Provider Seeking Reimbursement for Medical Claims.

Please click on the box below to access the Bayer $0 Co-pay Assistance Programs Expenditure Form for Providers. The form also includes instructions for completing and submitting the form for a Bayer $0 Co-pay Assistance Program. This form will be required for a Provider seeking reimbursement for medical claims.

Please send all required documentation to the following address and/or fax number below.

Bayer $0 Co-pay Assistance Programs
C/O ConnectiveRx Claims
Processing Center
P.O. Box 2355, Morristown, NJ 07962
Fax: (844) 622 -5475