Form Ma-5 - Claim Form - Department Of Public Health And Human Services

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STATE OF MONTANA – DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES
PLEASE TYPE O R PRINT
Return form to:
FOR USE BY PHARMACIES
FORM NO. MA-5
Claims Processing Unit, Dept. MA-5, P.O. Box 8000, Helena, MT 59604
Telephone 1-800-624-3958 or 406-442-1837
SECTION I – PROVIDER INFORMATION
1. Name – Provider
2. NPI
3. Address – Provider (Street, City, State, Zip Code)
4.
MHSP
Medicaid
SECTION II – RECIPIENT INFORMATION
5. Cardholder Identification Number – Recipient
6. Name – Recipient (Last, First, Middle Initial)
7. Date of Birth – Recipient
SECTION III – CLAIM INFORMATION
9. Prescription Type
10. Date Filled
11. Refill
12. Compound
8. Prescriber Number
Yes
No
Electronic
13. NDC
14. Days’ Supply
15. Quantity
16. Charge
17. Unit Dose
$
Yes
No
18. Prescription Number
19. DAW
20. Drug Description
21. Level of Effort
22. Sub Clar Code
23. Other Coverage Code
24. Total Charges
25. Other Coverage Amount
26. Patient Paid
27. Net Billed
$
$
$
$
8. Prescriber Number
9. Prescription Type
10. Date Filled
11. Refill
12. Compound
Yes
No
Electronic
13. NDC
14. Days’ Supply
15. Quantity
16. Charge
17. Unit Dose
$
Yes
No
18. Prescription Number
19. DAW
20. Drug Description
21. Level of Effort
22. Sub Clar Code
23. Other Coverage Code
24. Total Charges
25. Other Coverage Amount
26. Patient Paid
27. Net Billed
$
$
$
$
8. Prescriber Number
9. Prescription Type
10. Date Filled
11. Refill
12. Compound
Yes
No
Electronic
13. NDC
14. Days’ Supply
15. Quantity
16. Charge
17. Unit Dose
$
Yes
No
18. Prescription Number
19. DAW
20. Drug Description
21. Level of Effort
22. Sub Clar Code
23. Other Coverage Code
24. Total Charges
25. Other Coverage Amount
26. Patient Paid
27. Net Billed
$
$
$
$
8. Prescriber Number
9. Prescription Type
10. Date Filled
11. Refill
12. Compound
Yes
No
Electronic
13. NDC
14. Days’ Supply
15. Quantity
16. Charge
17. Unit Dose
$
Yes
No
18. Prescription Number
19. DAW
20. Drug Description
21. Level of Effort
22. Sub Clar Code
23. Other Coverage Code
24. Total Charges
25. Other Coverage Amount
26. Patient Paid
27. Net Billed
$
$
$
$
29. Certification – I certify that the care, services and supplies itemized have been furnished, the amounts listed are due and,
TOTAL
$
except as noted, no part thereof has been paid; payment of fees made in accordance with established schedules is
CHARGES
accepted as payment in full. I further certify that the services(s) indicated above has/have been provided without regard to
AMOUNT
$
race, color, national origin, creed, sex, religion, political ideas, marital status, age or handicap. I hereby agree to maintain
TO BE PAID
and furnish on request to the Department, the Montana Medicaid Fraud Control Bureau, the U.S. DHHS, the Comptroller
BY
General of the U.S., or any of their duly authorized agents or representatives such records as necessary to disclose fully
MEDICAID
the extent of care, s ervices, and supplies provided to individuals under the Montana Medical Assistance Program. I
UNDERSTAND THAT PAYMENT OF THIS CLAIM WILL BE FROM FEDERAL AND STATE FUNDS, AND THAT ANY
FALSIFICATION, OR CONCEALMENT OF A MATERIAL FACT, M AY BE PROSECUTED UNDER FEDERAL AND
STATE LAWS. I hereby agree to comply with all rules and requirements pertaining to the Montana Medicaid Program,
including but not limited to Title XIX of the Social Security Act, Montana Statues and the Administrative Rules of Montana.
Signature – Pharmacist or Dispensing Physician
Date Signed
AMOUNT
$
TO BE PAID
BY
RECIPIENT

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