Prescription Reimbursement Claim Form
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1
213477
Rev. 07/06
AmeriHealth Insurance Company of New Jersey
Prescription Reimbursement Claim Form
QCC Insurance Company d/b/a AmeriHealth Insurance Company
AmeriHealth HMO, Inc.
Part 1
Cardholder ID No.
RX PCN O3820000
Cardholder/
Cardholder Name
Address
Patient
City
State
ZIP
Phone (
)
Information
Patient Information — Use a separate claim form for each family member
Part 1 must be
fully completed
Patient Name
Date of Birth
to ensure proper
reimbursement
Patient: m Male m Female
Relationship: m Member m Spouse
m Child
m Other ________________
of your drug
Are any of these medications being taken for an on-the -job injury?
m Yes
m No
claim.
Please type or
I certify that I (or my eligible dependent) have received the medication described herein and that the patient named is eligible for prescription
benefits. I also certify that the medication received is not for treatment of an on-the-job injury or covered under another benefit plan. I authorize
print clearly.
release of all information pertaining to this claim to FutureScripts, the prescription benefit manager or its processing subcontractor; insurance
underwriter; plan sponsor; policyholder; and/or employer. I certify that all the information entered on this form is correct
.
Fraud Prevention Regulation: 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.
x
Signature of Cardholder or Legal Representative
Date
Part 2
Original receipts must be included with the following information. NOTE: Do not staple or tape receipts or attachments to
Important
this form.
Please remember
•
Member Name
•
Metric Quantity/Days supply
•
Total Charge
•
Drug Strength or NDC Number
to include all
•
Date of Purchase
•
Prescription Number
•
Drug Name
•
Pharmacy Name and Address or NABP Number
original pharmacy
receipts
.
Part 3
•
To ensure that your patient receives accurate and timely reimbursement for medication purchases, please assist in completing the information
below. Please enter COMPOUND RX in the space designated for the NDC # and complete the Compound Prescriptions section on the reverse side.
Pharmacy
Information
Pharmacy Name
Pharmacy NABP No. ________________________
Pharmacist to
Pharmacy Address
City ____________________________________
complete this
section ONLY
State
ZIP
Phone (
) _____________________________
if compound
prescription
I hereby certify that all the information listed below is correct and represents the actual charge(s) for prescription(s) dispensed. I further understand
that all benefit payments as related to the charges listed below will be paid directly to the cardholder.
x
Signature of Pharmacist or Representative
Date
For office use only
New
Refill
DAW
Compound
m
m
m
m
Prior Approval Code
Rx #
Date Filled (mm/dd/yy)
Prescriber’s DEA No.
Rx 1
NDC #
Drug Name and Strength
Metric Quantity
Days Supply
Total Charges
For office use only
New
Refill
DAW
Compound
m
m
m
m
Prior Approval Code
Rx #
Date Filled (mm/dd/yy)
Prescriber’s DEA No.
Rx 2
NDC #
Drug Name and Strength
Metric Quantity
Days Supply
Total Charges
For office use only
New
Refill
DAW
Compound
m
m
m
m
Prior Approval Code
Rx #
Date Filled (mm/dd/yy)
Prescriber’s DEA No.
Rx 3
NDC #
Drug Name and Strength
Metric Quantity
Days Supply
Total Charges
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