Medical Claim Form

For reimbursement, complete items
1-9 of the claim form,
attach receipt(s) and submit to:

Tri-County Schools Insurance Group

c/o Delta Health Systems

P. O. Box 80

Stockton, CA 95201-3080


If you need Delta Health Systems to reimburse the provider,
then also sign item 10 and following the same procedures
listed above.


One claim form per patient.

Prescription Claim Form

Complete the claim form
and submit it to:


ProAct Inc.

1230 US HWY 11

Gouverneur, NY 13642

Attn: DMR Dept.


Mail Order Form

Costco Mail Order Pharmacy

215 Deininger Circle

Corona, CA  92880-9911


ProAct, Letter of Medical Necessity


JPA Delegate Forms

Designation of Delegate

Form 700


1176 LIVE OAK BOULEVARD, SUITE A | YUBA CITY, CA 95991 | 866-822-5299