Form C3001 - Coordination Of Benefits/direct Claim Form printable pdf download

Coordination of Benefits/Direct Claim Form

See the back for instructions. Complete all information.

An incomplete form may delay your reimbursement.

Member/Subscriber Information See your prescription drug ID card.

Claim Receipts

Tape receipts or itemized bills on the back.

Group No.

See back for details.

Check the appropriate box if any

Member ID

receipts or bills are for a:

„ Compound prescription

Member Name (First, Last)

Make sure your pharmacist lists ALL

the VALID 11-digit NDC numbers,

Street Address

ingredients, cost and quantities on

the receipt or bill.

„ Medication purchased outside of

City

State

Zip

the United States

Please indicate:

Patient Information

Country

Currency used

Patient Name (First, Last)

„ Allergy medication

Patient Date of Birth (Month/Day/Year)

Coordination of Benefits

Sex

Relationship to Plan Member

(Another Health Plan has paid a

„ Female

„

Self

Disabled Dependent

portion) Mark the appropriate box for

„ Male

„

Spouse

Dependent Parent

your primary coverage method. See the

„

Eligible Child

Nonspouse Partner

back for more information.

„

Dependent Student „

Other

Is this a coordination of benefits claim?

„Yes

„No

Pharmacy Information

„

Another Health Plan paid and you

are enclosing a statement that

Name of Pharmacy

outlines how much you paid and

how much the other carrier paid.

Street Address

„

Card Program

„

The Medco Pharmacy

(now a

part of the Express Scripts family

City

State

Zip

of pharmacies)

Telephone (include area code)

Any person who knowingly and with intent

Is this an on-site nursing home pharmacy? „Yes

„No

to defraud, injure, or deceive any insurance

company submits a claim or application containing

I hereby certify that the charge(s) shown for the medication(s) prescribed is correct and agree to provide Express

any materially false, deceptive, incomplete, or

Scripts or its agents reasonable access to records related to medication dispensed to this patient in accordance with

misleading information pertaining to such claim

applicable law. I further recognize that reimbursement will be paid directly to the plan member and assignment of

may be committing a fraudulent insurance act,

these benefits to a pharmacy or any other party is void.

which is a crime and may subject such person to

criminal or civil penalties, including fines and/or

imprisonment or denial of benefits.*

Signature of Pharmacist or Representative

NABP Number Required

Please tape receipts on the back.

(Required)

Acknowledgment

I certify that the medication(s) described above was received for use by the patient listed above, and that I (or the patient, if not myself)

am eligible for prescription drug benefits. I also certify that the medication received was not for an on-the-job injury or covered under

another benefit plan. I recognize that reimbursement will be paid directly to me and that assignment of these benefits to a pharmacy or

any other party is void.

Signature of Member

If allowed by law, you may assign the payment of this claim to your pharmacy. If your pharmacy is willing to accept assignment, do not complete this form.

Please request that your pharmacy contact Pharmacy Services at 1 800 922-1557 for assistance.

C3001 9-12

Form C3001 - Coordination Of Benefits/direct Claim Form

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