Pharmacy Benefit Services Prescription Drug Claim Form
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1
2PHARMACY benefit SeRViCeS
PReSCRiPtiOn DRUG CLAiM fORM
fOR OffiCe USe OnLY
Claim Number
A. SUbSCRibeR infORMAtiOn
ID #
Claim #
Subscriber’s Name
(Last)
(First)
(MI)
Street Address
City
State
ZIp
SUBSCRIBER’S SIGNATURE ______________________________________________________
b. PAtient infORMAtiOn
patient’s Name
(Last)
(First)
(MI)
Date of Birth
patient’s ID #
Male
Female
patient’s relationship to insured/subscriber:
Self
Spouse
Dependent
I certify that all Subscriber and patient Information is correct and the medication has been dispensed. I authorize release of any information relating to
this claim to EmblemHealth and all necessary third parties for purposes of claims investigation and payment, utilization review and audit.
pATIENT’S SIGNATURE ______________________________________________________
C. PHARMACY infORMAtiOn
NABp/NpI #
Telephone #
pharmacy Name
pharmacy Address
City
State
ZIp
pHARMACIST’S SIGNATURE ______________________________________________________
D1. PReSCRiPtiOn infORMAtiOn
Date Dispensed
Rx #
Name of Medication
New
Refill
NDC #
Qty Dispensed
Days Supply
Strength
prescriber’s Name
prescriber’s State License #
prescription Cost
$ ___, ___ ___ ___.___ ___
D2. PReSCRiPtiOn infORMAtiOn
Date Dispensed
Rx #
Name of Medication
New
Refill
NDC #
Qty Dispensed
Days Supply
Strength
prescriber’s Name
prescriber’s State License #
prescription Cost
$ ___, ___ ___ ___.___ ___
IMPORTANT: SEE REVERSE FOR INSTRUCTIONS
Group Health Incorporated (GHI), HIp Health plan of New York (HIp), HIp Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies.
EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.
80-6627 2/14
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