Pharmacy Services Prescription Drug Claim Form
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1
2PHARMACY SERVICES
PRESCRIPTION DRUG CLAIM FORM
A. SUBSCRIBER INFORMATION
FOR OFFICE USE ONLY
ID # __________________________________________
Claim # ______________________
Subscriber’s Name __________________________________________________________________________
(Last)
(First)
(MI)
Street Address _____________________________________________________________________________
City____________________________________________ State________________________ Zip__________
SUBSCRIBER SIGNATURE _________________________________________________________________
B. PATIENT INFORMATION
Patient’s Name _____________________________________________________________________________
(Last)
(First)
(MI)
Date of Birth ___ / ___ /_____
Male ____ Female ____ Patients ID # ____________________________
Patient’s relationship to insured: 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 GuildNet and all necessary third parties, including
GHI and HIP, for purposes of claims investigation and payment, utilization review and audit.
PATIENT’S SIGNATURE: ___________________________________________________________________
C. PHARMACY INFORMATION
NABP # ____________________________
Telephone # ______ - ______ - ____________
Pharmacy Name ____________________________________________________________________________
Pharmacy Address _____________________________________City__________ State_______ Zip_________
I certify that the prescription(s) listed below were lawfully dispensed for the above-named patient, information
provide is correct and all supporting document is available for audit.
PHARMACIST’S SIGNATURE _____________________________________________________________
D1. PRESCRIPTION INFORMATION
Date Dispensed ___ /___ / _____ Rx # __________
New or Refill Name of Medication _____________
(Circle One)
NDC # __________________ Qty Dispensed _______ Days Supply _____ Strength _____
Prescriber’s Name ______________________________ Prescriber’s State License # ____________________
Prescription Cost $ __, __ __ __.__ __
D2. PRESCRIPTION INFORMATION
Prescription Cost $ __, __ __ __.__ __
Date Dispensed ___ /___ / _____ Rx # __________
New or Refill Name of Medication _____________
(Circle One)
NDC # __________________ Qty Dispensed _______ Days Supply _____ Strength _____
Prescriber’s Name ______________________________ Prescriber’s State License # ____________________
D3. PRESCRIPTION INFORMATION
Date Dispensed ___ /___ / _____ Rx # __________
New or Refill Name of Medication _____________
(Circle One)
NDC # __________________ Qty Dispensed _______ Days Supply _____ Strength _____
Prescriber’s Name: _____________________________ Prescriber’s State License # ____________________
Prescription Cost $ __, __ __ __.__ __
IMPORTANT: SEE REVERSE FOR INSTRUCTIONS
H6864_DPhRF08_04/08
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