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Vantage Flex, LLC
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Provider Prescription Claim
If you have questions, or would like to speak with a Vantage Flex representative, feel free to contact us at 906-863-3539.
Provider Information
Pharmacy Name:
*
Email Address:
Address:
*
City:
*
State:
*
Zip Code:
*
Patient Information
First Name:
*
Last Name:
*
Address:
*
City:
*
State:
*
Zip Code:
*
Date of Service:
*
Name of Prescription:
*
Prescription Reference Number:
*
Employer Name:
*
Comments:
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