Form Gc-1360 - Aenta Prescription Drug Claim Form (Page 2 of 2) in pdf

Member

• Please read carefully before completing this form. Claim forms without the required information cannot

be processed. Incomplete forms will be returned to you.

• Take this claim form to the pharmacy when you obtain prescription drugs.

• If you use more than one pharmacy, use a separate form for each pharmacy.

• Use a separate claim form for each patient.

• Claims must be submitted within two years of date of purchase.

• Complete all employee and patient information on the top portion of the form and be sure to sign it.

• Give the claim form to your pharmacist to complete the bottom portion.

• • • • Mail the Prescription Drug Claim Form to: Aetna

Pharmacy Management

Attn: Claim Processing

P.O. Box 398106

Minneapolis, MN 55439-8106

Pharmacist

• Complete bottom portion of form in full.

• Please include complete name and address of the pharmacy, NABP number, and authorized signature. Your

signature attests that all information, including total charge, is correct. Incomplete claim forms will be returned.

Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the

insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny

insurance benefits if false information materially related to claim was provided by the applicant. California

Residents: For your protection, California law requires notice of the following: Any person who knowingly and with

intent to defraud or deceive any insurance company files a statement of claim containing any materially false,

incomplete or misleading information is guilty of a crime and may be subject to fines, confinement in a state prison

and substantial civil penalties.

Colorado Residents: An insurer or agent who knowingly provides false or misleading information to

defraud a claimant regarding insurance proceeds must be reported to the Insurance Division.

Pennsylvania Residents: 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.

Form Gc-1360 - Aenta Prescription Drug Claim Form Page 2