Flexible Rx Rebateweb

Flexible Rx RebateWeb

Manufacturer > Register Organization

To register an organization to RebateWeb, complete this form and click 'Submit.'

Required*

Organization Name:*

Mailing Address:

Address Line 1:*

Address Line 2:

City:*

State (select one):*

Zip Code (12345 or 123456789)*

CMS Invoice Contact:

Name (Full Name):*

Email (email@host.com):*

Phone Number ((999) 999-9999 x9999):* ()-x

Organization Administrator:

same as CMS Invoice Contact

Name (Full Name):*

Email (email@host.com):*

Phone Number ((999) 999-9999 x9999):* ()-x

Associated Labeler Codes *

Select	Labeler Cd	Start Quarter	End Quarter