Pharmacy Services Prescription Drug Claim Form (Page 2 of 2) in pdf

Pharmacy Services Prescription Drug Claim Form Page 2

INSTRUCTIONS

PLEASE PRINT ALL SECTIONS

1. This form is to be used to claim prescription drug benefits provided to eligible GuildNet Gold members.

2. Please complete all sections. We need all the information requested to process your claims.

3. Copy subscriber’s/patient’s information from your GuildNet Gold Identification Card - see sample

below.

4. Have your pharmacist complete sections C, D1, D2, and D3. Receipts must be attached.

5. Use a separate form for each subscriber/patient. In addition, use a separate form for each pharmacy

serving the patient.

6. Send the form to: GuildNet Gold, P.O. Box 1520 JAF Station, New York, NY 10116-1520.

Pharmacy Services Prescription Drug Claim Form Page 2