Retail Prescription Drug Overseas Claim Form - Federal Employee Program
Download a blank fillable Retail Prescription Drug Overseas Claim Form - Federal Employee Program in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Retail Prescription Drug Overseas Claim Form - Federal Employee Program with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Federal Employee Program
®
RETAIL PRESCRIPTION DRUG OVERSEAS CLAIM FORM
®
®
®
INSTRUCTIONS
This form is to provide direct reimbursement for prescriptions that were purchased outside the United States.
Pharmacy receipts and Enrollee/Patient signature are required.
Please use a separate claim form for each patient.
Do not staple receipts or attachments to this form.
See instructions on the back of the claim form.
ENROLLEE’S OR POLICY HOLDER’S INFORMATION REQUIRED:
IDENTIFICATION NUMBER
Insured’s
R
Name:
EMAIL ADDRESS
Street
Address:
Mail Completed Form To:
Service Benefit Plan
:
State
Zip:
City
Retail Pharmacy Program
P.O. Box 52057
Country:
Phoenix, AZ 85072-2057
I certify that the information is correct and complete and that I am claiming benefits only for the charges for the patient named below.
Authorization is hereby given to any provider of service who participated in any way in the patient’s care, to release any medical information,
which they deem necessary to adjudicate this claim. I also authorize release of all information contained on this claim to CVS Caremark and the
plan administrator. I agree that any benefits payable hereunder for prescription drugs are not assignable and that any assignment of these
benefits shall be void.
PATIENT INFORMATION REQUIRED:
LAST
FIRST
Patient’s Relationship to insured:
Patient
Name:
Self
Spouse
Dependent
Date of Birth:
Male:
Female:
FOREIGN COUNTRY INFORMATION:
Country Where Drugs Purchased:
(one medication per line)
PRESCRIPTION CLAIM INFORMATION:
MONTH
DAY
YEAR
Date Purchased
Quantity (how many)
Days Supply:______________________
Name of Medication _________________________________________________________________________________________________
U.S. Drug Equivalent Name____________________________________________________________________________________________
Form of Medication (capsules, cream, etc.) __________________Strength (250 mg., etc.): __________________________________________
Prescription Cost: ___________________
Country Currency Type_____________________________________________________
MONTH
DAY
YEAR
Date Purchased
Quantity (how many)
Days Supply:______________________
Name of Medication _________________________________________________________________________________________________
U.S. Drug Equivalent Name____________________________________________________________________________________________
Form of Medication (capsules, cream, etc.) __________________Strength (250 mg., etc.): __________________________________________
Prescription Cost: ___________________
Country Currency Type_____________________________________________________
MONTH
DAY
YEAR
Date Purchased
Quantity (how many)
Days Supply:______________________
Name of Medication _________________________________________________________________________________________________
U.S. Drug Equivalent Name____________________________________________________________________________________________
Form of Medication (capsules, cream, etc.) __________________Strength (250 mg., etc.): __________________________________________
Prescription Cost: ___________________
Country Currency Type_____________________________________________________
Enrollee/Patient Signature:_________________________________________________________ Date:_____________________________
CUT0154-1S F 12/13
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business