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:

EnvisionRx Options, Inc.
2181 East Aurora Road, Suite 201
Twinsburg, Ohio 44087

Mail Order Form

Orchard Pharmaceuticals
P. O. Box 3094
North Canton, OH 44720

Physician Fax Order Form
for Mail Order

Envision, Letter of Medical Necessity

Envision, Letter of Medical Necessity -
Proton Pump Inhibitor (PPI)

IHS Fax Your Results