Fillable Prescription Reimbursement Claim Form printable pdf download

Prescription Reimbursement Claim Form

Part 1

Cardholder ID No.

Cardholder/

Cardholder Name

Address

Member

City

State

Zip

Information

Member Information - Use a separate claim form for each family member

Part 1 must be

Date of Birth _____/_____/_____

Member Name

fully completed

Member:  Male  Female

Relationship:  Self  Spouse  Child  Other ___________

to ensure proper

Are any of these medicines being taken for an on-the-job injury:

 Yes

 No

reimbursement of

Is the medicine covered under any other group insurance?

 Yes

 No

your claim.

If yes, is other coverage:

Primary

Secondary

If other coverage is Primary, include the explanation of benefits (EOB) with



Please type or

this form.

print clearly.

Name of Insurer

Policy #

ID #

Phone (

)

I certify that I (or my eligible dependent) have received the medicine described herein and that the member named is eligible

for prescription benefits. I also certify that the medicine received is not for treatment of any on-the-job injury or covered under

another benefit plan. I authorize release of all information pertaining to this claim to CVS/Caremark, the plan administrator,

insurance underwriter, plan sponsor, policyholder and/or employer. I certify that all the information entered on this form is correct.

_______/_______/_______

Signature of Cardholder or Legal Representative

Date

Part 2

• Member Name

• Pharmacy Name and address or NABP Number

• Prescription Number

Important!

• Date Purchased

• Total Charge

• Medicine Strength/or NDC Number • Medicine Name

Please remember

to include all

• Metric Quantity, Days Supply

original pharmacy

receipts.

Part 3

• To ensure that the member receives accurate and timely reimbursement for medical purchases, please assist in completing the

information below.

Pharmacy

• If compound prescription, please enter COMPOUND RX in the space designated for the NDC # and complete the Compound

Information

Prescriptions sections on the reverse side.

Pharmacy Name

Pharmacy NABP No.

Pharmacist to

Pharmacy Address

City

complete this

State

Zip

Phone (

)

section ONLY if

I hereby certify that all the information listed below is correct and represents the actual charge(s) for prescription(s) dispensed. I

further understand that all benefits payments as related to the charges listed below will be paid directly to the cardholder.

original pharmacy

receipts are not

Signature of Pharmacist of Representative

Date

included.

(Required only if original pharmacy receipts are not included)

For office use only

| | | | | | | |

 New  Refill  DAW  Compound

Prior Approval Code

Rx #

Date Filled (mm/dd/yy)

Prescriber’s DEA No.

Rx 1

Medicine Name and Strength

Metric Quantity

Days Supply

Total Charges

NDC #

For office use only

| | | | | | | |

 New  Refill  DAW  Compound

Prior Approval Code

Rx #

Date Filled (mm/dd/yy)

Prescriber’s DEA No.

Rx 2

Medicine Name and Strength

Metric Quantity

Days Supply

Total Charges

NDC #

For office use only

| | | | | | | |

 New  Refill  DAW  Compound

Prior Approval Code

Rx #

Date Filled (mm/dd/yy)

Prescriber’s DEA No.

Rx 3

NDC #

Medicine Name and Strength

Metric Quantity

Days Supply

Total Charges

Fraud Prevention Regulation:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for

insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact

material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

P-4303 1/16

Prescription Reimbursement Claim Form

Related Articles

Related forms

Related Categories