Compound Drug Claim Form
Download a blank fillable Compound Drug Claim Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Compound Drug Claim Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
DHS 106.03(1), Wis. Admin. Code
F-13073 (07/12)
COMPOUND DRUG CLAIM
Instructions: Type or print clearly. Before completing this form, read the Compound Drug Claim Completion Instructions, F-13073A. Return the
completed form to: ForwardHealth, Claims and Adjustments, 313 Blettner Boulevard, Madison, WI 53784.
SECTION I — PROVIDER INFORMATION
1. Name — Provider
2. National Provider Identifier
3. Address — Provider (Street, City, State, ZIP+4 Code)
SECTION II — MEMBER INFORMATION
4. Member Identification Number
5. Name — Member (Last, First, Middle Initial)
6. Date of Birth — Member
7. Sex — Member
8. Copay Exempt
SECTION III — CLAIM INFORMATION
9. Prescriber Number
10. Date Prescribed
11. Date Filled
12. Refill
13. Days' Supply
14. Quantity Dispensed
15. Prescription Number
16. Place of Service
17. Diagnosis Code
18. Level of Effort
SECTION IV — COMPOUND INGREDIENTS
Ingredient NDC
Ingredient Quantity
Ingredient Cost
Ingredient NDC
Ingredient Quantity
Ingredient Cost
1.
14.
$
$
Ingredient NDC
Ingredient Quantity
Ingredient Cost
Ingredient NDC
Ingredient Quantity
Ingredient Cost
2.
15.
$
$
Ingredient NDC
Ingredient Quantity
Ingredient Cost
Ingredient NDC
Ingredient Quantity
Ingredient Cost
3.
16.
$
$
Ingredient NDC
Ingredient Quantity
Ingredient Cost
Ingredient NDC
Ingredient Quantity
Ingredient Cost
4.
17.
$
$
Ingredient NDC
Ingredient Quantity
Ingredient Cost
Ingredient NDC
Ingredient Quantity
Ingredient Cost
5.
18.
$
$
Ingredient NDC
Ingredient Quantity
Ingredient Cost
Ingredient NDC
Ingredient Quantity
Ingredient Cost
6.
19.
$
$
Ingredient NDC
Ingredient Quantity
Ingredient Cost
Ingredient NDC
Ingredient Quantity
Ingredient Cost
7.
20.
$
$
Ingredient NDC
Ingredient Quantity
Ingredient Cost
Ingredient NDC
Ingredient Quantity
Ingredient Cost
8.
21.
$
$
Ingredient NDC
Ingredient Quantity
Ingredient Cost
Ingredient NDC
Ingredient Quantity
Ingredient Cost
9.
22.
$
$
Ingredient NDC
Ingredient Quantity
Ingredient Cost
Ingredient NDC
Ingredient Quantity
Ingredient Cost
10.
23.
$
$
Ingredient NDC
Ingredient Quantity
Ingredient Cost
Ingredient NDC
Ingredient Quantity
Ingredient Cost
11.
24.
$
$
Ingredient NDC
Ingredient Quantity
Ingredient Cost
Ingredient NDC
Ingredient Quantity
Ingredient Cost
12.
25.
$
$
Ingredient NDC
Ingredient Quantity
Ingredient Cost
13.
$
19. Other Coverage Code
20. Charge
21. Other Coverage Amount
22. Patient Paid Amount
23. Net Billed
$
$
$
$
24. Certification
I certify that the services and items for which reimbursement is claimed on this claim form were provided to the previously named member pursuant to the prescription of a
licensed physician, podiatrist, or dentist. Charges on this claim form do not exceed my (our) usual and customary charge for the same services or items when provided to
persons not entitled to receive benefits under ForwardHealth.
I understand that any payment made in satisfaction of this claim will be derived from federal and state funds and that any false claims, statements or documents, or
concealment of a material fact may be subject to prosecution under applicable federal or state law.
25. SIGNATURE — Pharmacist or Dispensing Physician
26. Date Signed
Reset Form
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal