Direct Member Reimbursement Form
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1
2DIRECT MEMBER REIMBURSEMENT FORM
Check here if this is a new address or address change
Part 1
Cardholder ID No.
Group No./Group Name
Member
Information
Cardholder Name
Address
Part 1 must be fully
completed to ensure proper
reimbursement of your drug
City
State
ZIP
Phone (
)
claim. Claims older than 6
months are not eligible for
Patient Information-Use a separate claim form for each family member
reimbursement.
Patient Name
ID No.
Date of Birth
Please type or print clearly.
Patient :
Male
Female
Relationship:
Spouse
Child
Other
Are any of these medications being taken for an on-the-job injury?
Yes
No
Is the medication covered under any other group insurance?
Yes
No
If yes, complete Part 2.
Important! Please remember to include all original pharmacy receipts.
Has your claim been processed with another insurance carrier?
Yes
No
Part 2
Coordination of
If yes, attach a copy of your EOB or statement from the other coverage and/or your receipt from the pharmacy.
Benefits
Name of insured policyholder:
* Your policy/plan must have
Name of insured’s company:
a pharmacy COB clause in
order to coordinate benefits.
Name of other insurance company:
Policy number (other insurance company):
Type of coverage:
Single
Family
I certify that I (or my eligible dependent) have received the medication described herein and that the patient named is eligible for drug benefits. I also certify that the medication received
is not for the treatment of an on-the-job injury, or covered under another benefit plan unless Part 2 is completed. I authorize release of all information pertaining to this claim to Argus
Health Systems, Inc., the plan administrator, insurance underwriter, plan sponsor, policyholder, and/or employer. I certify that all the information entered on this form is correct.
X
Signature of Member or Legal Representative
Date
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 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 civil penalties.
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