Claim Form

Pharmacy Reimbursement Claim Form enchant read the back for instructions. distinguish all culture. An incomplete form may delay your reimbursement. outgrowth/Subscriber Information See your ID card. RxGrp Member ID Member have-to doe with (First, Last) track Address City patient role Information Patient Name (First, Last) Patient Date of Birth (Month/Day/Year) sex Relationship to Member/Subscriber ? Female ? 1 self ? 5 Disabled Dependent ? Male ? 2 mate ? 6 Dependent Parent ? 3 Eligible nipper ? 7 Nonspouse Partner ? 4 Dependent Student ? 8 Other Pharmacy Information Name of Pharmacy Street Address City Telephone (include area code) State zilch State Zip Claim Receipts (Please read function A on back for details.) Check the appropriate misfortune if your pass along are for a: ? Compound prescription Make reliable your pharmacist lists ALL the VALID 11 digit NDC poesy and ingredients and quantities on the receipt. ? Medication purchased outside of the United States Please level: Country Currency used ? Allergy medication (if cover by your pharmacy plan) Coordination of Benefits (Another Health Plan has paid a portion) Is this a coordination of benefits claim? ?Yes ?No If yes, please read Section B on back for details, and mark the appropriate box for your primary coverage method.

? 1 You are submitting an Explanation of Benefits (EOB) from some other Health Plan or from Medicare ? 3 You are submitting a copay receipt Any person who knowingly and with intent to defraud, injure, or cheat any insurance company, submits a claim or diligence containing any materially false, deceptive, incomplete or misleading information pertaining to such claim may be committing a two-faced insurance act which is a crime and may landing field such person to criminal or civil penalties, including fines and/or imprisonment, or denial of benefits.* X Signature of Pharmacist or case (If required by your pharmacy plan) NCPDP#/NPI# (Pharmacy Account Number) (11 Digit Number) Please tape receipts... If you want to get a full essay, instal it on our website: Orderessay

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