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

Please read REVERSE SIDE before completing this form. (PLEASE PRINT)

Cardholder Name:_________________________________________________________________________

First

Middle

Last

Cardholder ID Number: _________________________ 4-digit Carrier / Plan / Group Code: ____________

Cardholder Address: ______________________________________________________________________

Street

______________________________________________________________________

City

State

Zip

Employer Name:___________________________ Insurance Company:_____________________________

Patient Name:_____________________________________________________________________________

First

Middle

Last

Person Code____________

Patient’s Date of Birth____ /____ /____ Patient Sex: M F (Circle One)

If your medication is covered under ANY OTHER Insurance Plan, provide the name of the Employer and Insurance Company:

_________________________________________________________________________________________

Note: If the Primary Insurance Company does not pay a pharmacy benefit, an Explanation of Benefits from the Primary

Insurance Company OR a print-out from the pharmacy explaining the reason for non-payment should be submitted with this

claim form.

I certify that the above information is correct and that the person is eligible for benefits. I have received the medication

described below and authorize release of all information contained on this voucher to Restat and the underwriter.

I agree that any benefits payable hereunder for prescription drugs are not assignable and that any assignment or attempted

assignment thereof shall be void. I further represent that there has been no assignment of benefits hereunder.

CARDHOLDER SIGNATURE: _______________________________________________________________

To receive reimbursement:

Attach copies of prescription receipts showing the following information:

 Pharmacy Name and Address

Patient Name

 Prescription Number

Fill Date

 Drug Name and Strength

Quantity & Days supply

 Drug Cost

Amount Paid

Your claim cannot be processed unless this form is complete.

Prescription Drug Claim Form Page 2