Prescription Drug Claim Form - Express Scripts Form
Download a blank fillable Prescription Drug Claim Form - Express Scripts Form 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 Prescription Drug Claim Form - Express Scripts Form 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
2®
PRESCRIPTION DRUG CLAIM FORM
DIV
NGC
Cardholder’s Name (Last, First, MI)
Date of Birth
Gender
Cardholder ID Number
(circle)
M
F
,
,
Check if new address
Address
Street_______________________________________________________________________________________________________
City/State________________________________________ Zip Code______________ Daytime Telephone (_____)_______________
Employer
Insurance Carrier
Group Number
PLEASE SIGN AND DATE HERE
: I certify that all information provided is correct and that the prescription(s) submitted are for me or members of my family who are eligible. The
patient(s) listed below has (have) received the medication, and I authorize release of all information contained on this claim to Express Scripts, Inc. and my Plan Sponsor. 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.
Cardholder’s Signature
Date
Patient Information (please list information for each patient submitting claims)
1
Patient’s Name
Relationship to
Gender
Date of Birth
Total number of
Cardholder?(circle)
(circle)
receipts attached:
Self, spouse, dependent
M
F
Pharmacy Name and Address:
Physician Name (name of prescribing Doctor) and DEA#:
2
Patient’s Name
Relationship to
Gender
Date of Birth
Total number of
Cardholder?(circle)
(circle)
receipts attached:
Self, spouse, dependent
M
F
Pharmacy Name and Address:
Physician Name (name of prescribing Doctor) and DEA#:
3
Patient’s Name
Relationship to
Gender
Date of Birth
Total number of
Cardholder?(circle)
(circle)
receipts attached:
Self, spouse, dependent
M
F
Pharmacy Name and Address
Physician Name (name of prescribing Doctor) and DEA#:
no. If Yes, Please provide receipt stating: Pharmacy Name/Address • Date Filled • Type of Insulin
Is claim for DIABETIC SUPPLY?
yes
and/or Type of supply • Quantity • Days Supply • Price •Patient’s Name. Cash register receipts are acceptable but Pharmacist Signature is
required if any information is handwritten.
***Ask your pharmacist how you can purchase diabetic supplies with your prescription card***
Does the patient reside in an assisted living facility?
yes
no
Is this claim for allergy serum?
yes
no
Does the patient have primary prescription drug coverage through another insurance carrier?
yes
no
Did the patient submit this claim to the other carrier?
yes
no
If yes, please attach an explanation of benefits from your primary carrier.
Prescription Information
All
prescription claims must have prescription receipts/labels which include:
IMPORTANT
• Pharmacy Name/Address • Date Filled • Drug Name, Strength and NDC • Rx Number • Quantity • Days Supply • Price • Patient’s Name
Claims received missing any of the above information may be returned or payment may be denied or delayed
⌧ Please tape receipts to separate piece of paper.
⌧ Patient history print outs from the pharmacy are also acceptable but MUST be signed by the Pharmacist.
⌧ CASH REGISTER RECEIPTS ARE NOT ACCEPTABLE FOR ANY PRESCRIPTIONS.
(With the exception of diabetic supplies)
REASON FOR CLAIM SUBMISSION OR SPECIAL NOTES:
ESI USE ONLY
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business