Alaska Prescription Drug Monitoring Program Universal Claim Form

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ALASKA PRESCRIPTION DRUG MONITORING PROGRAM
UNIVERSAL CLAIM FORM
The State of Alaska now requires that ALL Prescriptions for Schedule II-V Controlled Substance and designated drugs of concern be reported to a data repository
managed by the Alaska Board of Pharmacy
Fax: (888) 288-0337
Fax or Mail to
391 Industry Dr
(
Health Information Designs
Auburn, AL 36832
Phone:
800) 225-6998
PATIENT INFORMATION
First Name _____________________________________
MI ____
Last Name ___________________________________________________
*Veterinarians should enter the animal’s first name or species.
*Veterinarians should enter the owner’s last name.
Identification Number _________________________________________
Identification Number Identifier: (Optional)
Military ID
State Issued ID
Unique System ID
Passport ID
Driver’ s License ID
Other
SSN
Tribal ID
DOB _____/_____/__________
Gender
Unknown
M
F
*Veterinarians should enter the animal’s approximate DOB.
*Veterinarians should enter the animal’s gender.
Address _______________________________________________
City ___________________________
State _____
ZIP _________
*Veterinarians should enter the owner’s address information.
DISPENSER INFORMATION
Dispenser Name _________________________________
DEA _____________________________
Phone # (_________)_________-______________
Fax # (_________)_________-______________
Address _______________________________________________
City ___________________________
State _____
Zip _________
PRESCRIPTION INFORMATION
Prescription #_____________________________
Reporting Status
New Record
Revise
Void
NDC
-
-
Drug Name Strength)_____________________________________
Quantity Dispensed_____________________
Days Supply ___________________________
Refill # _________________________
Date Written _____/_____/_________
Date Filled _____/_____/_________
Refills Authorized_________________
Prescriber Name______________________________
DEA_____________________________
NPI______________________________
Prescriber Phone # (_________)_________-______________
Prescriber Fax # (_________)_________-______________
Classification Code for Payment Type
Private Pay
Medicaid
Medicare
Commercial Insurance
Military Installations/VA
Workers’ Compensation
Indian Nations
Other
Prescription #_____________________________
Reporting Status
New Record
Revise
Void
-
-
NDC
Drug Name (Strength)___________________________________
Quantity Dispensed_____________________
Days Supply ___________________________
Refill # _________________________
Date Written _____/_____/_________
Date Filled _____/_____/_________
Refills Authorized_________________
Prescriber Name______________________________
DEA_____________________________
NPI______________________________
Prescriber Phone # (_________)_________-______________
Prescriber Fax # (_________)_________-______________
Classification Code for Payment Type
Private Pay
Medicaid
Medicare
Commercial Insurance
Military Installations/VA
Workers’ Compensation
Indian Nations
Other
Prescription #_____________________________
Reporting Status
New Record
Revise
Void
-
-
NDC
Drug Name (Strength)_______________________________________
Quantity Dispensed_____________________
Days Supply ___________________________
Refill # _________________________
Date Written _____/_____/_________
Date Filled _____/_____/_________
Refills Authorized_________________
Prescriber Name______________________________
DEA_____________________________
NPI______________________________
Prescriber Phone # (_________)_________-______________
Prescriber Fax # (_________)_________-______________
Classification Code for Payment Type
Private Pay
Medicaid
Medicare
Commercial Insurance
Military Installations/VA
Workers’ Compensation
Indian Nations
Other

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