Noncompound Drug Claim Form printable pdf download

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Health Care Access and Accountability

DHS 106.03(1), Wis. Admin. Code

F-13072 (10/12)

NONCOMPOUND DRUG CLAIM

Instructions: Type or print clearly. Before completing this form, read the Noncompound Drug Claim Completion Instructions,

F-13072A.

For questions, contact Provider Services at (800) 947-9627. For ForwardHealth members, return the completed form to:

ForwardHealth, Claims and Adjustments, 313 Blettner Boulevard, Madison, WI 53784.

For Wisconsin Chronic Disease Program members, return form to: ForwardHealth, P.O. Box 6410, Madison, WI 53716-0410.

For Wisconsin AIDS/HIV Drug Assistance Program members, return form to: ForwardHealth, ADAP Claims and Adjustments, P.O. Box

8758, Madison, WI 53708.

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 —

7. Sex —

8. Copay

Member

Exempt

SECTION III — CLAIM INFORMATION

9. Prescriber Number

10. Date Prescribed

11. Date Filled

12. Refill

13. NDC

14.Days'Supply

15. Quantity

16. Prescription Number

17. Drug Description

18. Special Package Indicator

19. Dispense as Written

20. Place of Service

21. Diagnosis Code

22. Level of Effort

23.Reason for Service

24.Professional Service

25. Result of Service

26. Other Coverage Code

27. Charge

28. Other

29. Patient Paid

30. Net Billed

Coverage Amount

Amount

31. Certification

I certify 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.

32. SIGNATURE — Pharmacist or Dispensing Physician

33. Date Signed

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