Form

Redirect a claim to your PBM

Use this form if a claimant's prescriptions should be billed through your PBM rather than through HealthLift. Once we have it, we place a block so future prescriptions for this claimant's date of injury reject at the pharmacy with your PBM's processing information.

Fields marked with an asterisk are required.

The claim

These details identify the claimant. We store them encrypted, use them only to find this claim, and never show them back after you submit.

Claimant first name

Claimant last name

Date of birth MM/DD/YYYY

Date of injury MM/DD/YYYY

Claim number (optional)

Insurance carrier (optional)

Employer (optional)

Agreement

Where to send confirmation

We email you once the block is in place.

Your name

Email address We send you a receipt here.

Company you represent (optional)

We use what you send only to act on this request. See our Privacy Notice, Terms of Use and HIPAA Notice.