This government document is issued by Veterans Resources for use in Maricopa County, AZ
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https://www.google.com/url?client=internal-element-cse&cx=007218899975830598806:668akstzics&q=https://www.maricopa.gov/DocumentCenter/View/61467/UHC-HDHP-Prescription-Reimbursement-Form-20-21&sa=U&ved=2ahUKEwi-qsS93570AhVRNOwKHRQmA1g4KBAWegQIBRAB&usg=AOvVaw2diF4vpQ4tZs695Olu9TCm