Medicare Part D Prescription Claim Form

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Part D Services
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Medicare Part D
This prescription was covered by a
manufacturer patient assistance program
Prescription Claim Form
Important!
* Always allow up to 30 days from the time you receive the response to allow for mail time
plus claims processing.
* Keep a copy of all documents submitted for your records.
* Do not staple or tape receipts or attachments to this from.
STEP 1
Card Holder/Patient Information
This section must be fully completed to ensure proper reimbursement of your claim.
Card Holder Information
Identification Number (refer to your prescription card)
Group No./Group Name
Name (Last Name)
(First Name)
(MI)
Address
City
State
Zip
Patient Information-Use a separate claim form for each patient.
Name (Last Name)
(First Name)
(MI)
Date of Birth
Phone Number
Male
Female
Relationship to Primary member
Member
Spouse
Child
Other_______________
Other Insurance Information
COB (Coordination of Benefits)
Are any of these medicines being taken for an on-the-job injury?
Yes
No
Is the medicine covered under any other group insurance?
Yes
No
If yes, is other coverage:
Primary
Secondary
If other coverage is Primary, include the explanation of benefits (EOB) with this form.
Name of Insurance Company____________________________ ID#________________________
Important! A signature is REQUIRED
NOTICE
Any person who knowingly and with intent to defraud, injure, or deceive any insurance company, submits a claim or application containing
any materially false, deceptive, incomplete or misleading information pertaining to such claim may be committing a fraudulent insurance
act which is a crime and may subject such person to criminal or civil penalties, including fines, denial of benefits, and/or imprisonment.
I certify that I (or my eligible dependent) have received the medicine described herein. I certify that I have read and understood this form,
and that all the information entered on this form is true and correct.
X
Signature of Plan Participant
Date
(Over)
Save to Disk
Save As...

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