6. H6864_GN144_Rx Reimbursement Form H6864 GN144 Rx

User Manual: 6.-H6864_GN144_Rx-Reimbursement-Form

Open the PDF directly: View PDF PDF.
Page Count: 2

Download6. H6864_GN144_Rx Reimbursement Form 6.-H6864_GN144_Rx-Reimbursement-Form 6.-H6864 GN144 Rx-Reimbursement-Form
Open PDF In BrowserView PDF
PHARMACY SERVICES
PRESCRIPTION DRUG CLAIM FORM
1. This form is to be used to claim prescription drug benefits provided to eligible GuildNet Gold members.
2. Please complete all sections. We need all the information requested to process your claims.
3. Have your pharmacist complete sections B and C. Receipts must be attached.
4. Use a separate form for each member. In addition, use a separate form for each pharmacy
serving the member.
5. Send the form and receipts to:
GuildNet Gold


A. SUBSCRIBER INFORMATION

FOR OFFICE USE

ID #

Claim #

Member Name (Last) (First) (MI)
Street Address
City
Date of Birth: ____/_____/______

State
Male

Female

ZIP

Member ID#

I certify that all Member Information is correct and the medication has been dispensed. I authorize release of any
information relating to this claim to GuildNet Gold, and all necessary third parties, including Emblem Health, for
purposes of claims investigation and payment, utilization review and audit.
MEMBER SIGNATURE

Please see next page.

H6864_GN144_Rx Reimbursement Form_GN Approved

B. PHARMACY INFORMATION
NABP #

Telephone number

Pharmacy Name

Pharmacy Street Address
City

State

ZIP

I certify that the prescription(s) listed below were lawfully dispensed for the above-named patient,
information provided is correct and all supporting documents are available for audit.
PHARMACIST’S SIGNATURE
C. PRESCRIPTION INFORMATION Name of Medication

Rx #

Date dispensed: ____/____/______
NDC#

Qty Dispensed
New

Strength

Days Supply

Rx Cost

Refill
$

Prescriber Name

Prescriber State License #

PRESCRIPTION INFORMATION

Name of Medication

Rx #

Date dispensed: ____/____/______
NDC#
New
Refill

Qty Dispensed

Days Supply

Strength

Rx Cost
$

Prescriber Name

Prescriber State License #

PRESCRIPTION INFORMATION

Name of Medication

Rx #

Date dispensed: ____/____/______
NDC#
New
Refill

Qty Dispensed

Days Supply

Strength

Rx Cost
$

Prescriber Name

Prescriber State License #

GuildNet Gold is a HMO-POS SNP plan with a Medicare and New York State Medicaid contract. Enrollment
in GuildNet Gold depends on contract renewal.
All beneficiaries must use their plan sponsor’s network pharmacies to access their prescription drug benefit,
except under non-routine circumstances. Limitations, co-payments and restrictions may apply.
This information is available for free in other languages. Please contact Member Services at 1-800-815-0000 for
additional information. (TTY users should call 1-800-662-1220.) Hours are Monday through Sunday, 8am to
8pm. Member Services also has free language interpreter services available for non-English (phone numbers
are printed on the back cover of this booklet).
Esta información está disponible en otros idiomas a gratis. Por favor llame a Servicio para los Miembros, al 1800-815-0000 para obtener información adicional. (Los usuarios de TTY deben llamar al 1-800-662-1220). Se
atiende lunes a domingo, 8am a 8pm. Servicio para los Miembros tienen servicios gratuitos de intérprete de
idioma disponibles para altavoces de no-inglés.



Source Exif Data:
File Type                       : PDF
File Type Extension             : pdf
MIME Type                       : application/pdf
Linearized                      : No
Page Count                      : 2
PDF Version                     : 1.4
Title                           : 6. H6864_GN144_Rx Reimbursement Form
Author                          : 
Subject                         : 
Producer                        : Mac OS X 10.10.1 Quartz PDFContext
Creator                         : Word
Create Date                     : 2015:03:05 23:06:54Z
Modify Date                     : 2015:03:05 23:06:54Z
Apple Keywords                  : 
EXIF Metadata provided by EXIF.tools

Navigation menu