Fillable rescription Drug Statement P (GEHA)

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rescription Drug Statement P (GEHA)

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GF-FRM-0517-001
P
rescription Drug Statement
To expedite the processing of your foreign prescription drugs, please complete this prescription drug
statement, attach a copy of your drug receipt(s) and submit to:
GEHA Foreign Claims Department
P.O. Box 21542
Eagan, MN 55121
(
Note: In some instances, your doctor’s prescription may be requested.)
Patient name:
GEHA member number:
Date of
Purchase
Name and Strength of Drug
Quantity
Number
of Days
Cost
Nature of Illness
or Injury
GEHA Foreign Claims Department
P.O. Box 21542 • Eagan, MN 55121
Telephone 800.821.6136 • Email overseas@geha.com • geha.com
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rescription Drug Statement P (GEHA)

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Completed 21 May 2021

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