CLM08_04 Rx Claim Reimbursement Form 2010 CLM08_04Rx CLM08 04Rx

CLM08_04RxClaimReimbursementForm_Old_09302011 CLM08_04RxClaimReimbursementForm_Old_09302011

CLM08_04RxClaimReimbursementForm CLM08_04RxClaimReimbursementForm

CLM08_04RxClaimReimbursementForm2010 CLM08_04RxClaimReimbursementForm2010

User Manual: CLM08_04RxClaimReimbursementForm

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PHARMACY SERVICES
PRESCRIPTION DRUG CLAIM FORM
A. SUBSCRIBER INFORMATION
FOR OFFICE USE ONLY
ID # __________________________________________
Claim # ______________________
Subscriber’s Name __________________________________________________________________________
(Last)
(First)
(MI)
Street Address _____________________________________________________________________________
City____________________________________________ State________________________ Zip__________
SUBSCRIBER SIGNATURE _________________________________________________________________
B. PATIENT INFORMATION
Patient’s Name _____________________________________________________________________________
(Last)
(First)
(MI)
Date of Birth ___ / ___ /_____ Male ____ Female ____ Patients ID # ____________________________
Patient’s relationship to insured: Self ___ Spouse ___ Dependent ___
I certify that all Subscriber and Patient Information is correct and the medication has been dispensed. I
authorize release of any information relating to this claim to GuildNet and all necessary third parties, including
GHI and HIP, for purposes of claims investigation and payment, utilization review and audit.
PATIENT’S SIGNATURE: ___________________________________________________________________
C. PHARMACY INFORMATION
NABP # ____________________________
Telephone # ______ - ______ - ____________
Pharmacy Name ____________________________________________________________________________
Pharmacy Address _____________________________________City__________ State_______ Zip_________
I certify that the prescription(s) listed below were lawfully dispensed for the above-named patient, information
provide is correct and all supporting document is available for audit.
PHARMACIST’S SIGNATURE _____________________________________________________________
D1. PRESCRIPTION INFORMATION
Date Dispensed ___ /___ / _____ Rx # __________ New or Refill Name of Medication _____________
(Circle One)

NDC # __________________ Qty Dispensed _______ Days Supply _____ Strength _____
Prescriber’s Name ______________________________ Prescriber’s State License # ____________________
Prescription Cost $ __, __ __ __.__ __
D2. PRESCRIPTION INFORMATION
Prescription Cost $ __, __ __ __.__ __
Date Dispensed ___ /___ / _____ Rx # __________ New or Refill Name of Medication _____________
(Circle One)

NDC # __________________ Qty Dispensed _______ Days Supply _____ Strength _____
Prescriber’s Name ______________________________ Prescriber’s State License # ____________________
D3. PRESCRIPTION INFORMATION
Date Dispensed ___ /___ / _____ Rx # __________

New or Refill

Name of Medication _____________

(Circle One)

NDC # __________________ Qty Dispensed _______ Days Supply _____ Strength _____
Prescriber’s Name: _____________________________ Prescriber’s State License # ____________________
Prescription Cost $ __, __ __ __.__ __
IMPORTANT: SEE REVERSE FOR INSTRUCTIONS

H6864_DPhRF08_04/08

INSTRUCTIONS
PLEASE PRINT ALL SECTIONS

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. Copy subscriber’s/patient’s information from your GuildNet Gold Identification Card - see sample
below.
4. Have your pharmacist complete sections C, D1, D2, and D3. Receipts must be attached.
5. Use a separate form for each subscriber/patient. In addition, use a separate form for each pharmacy
serving the patient.
6. Send the form to: GuildNet Gold, P.O. Box 1520 JAF Station, New York, NY 10116-1520.
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Title                           : Microsoft Word - CLM08_04 Rx Claim Reimbursement Form 2010.doc
Author                          : gikowd
Creator                         : Microsoft Word - CLM08_04 Rx Claim Reimbursement Form 2010.doc
Producer                        : doPDF   Ver 6.1 Build 286 (Windows XP  x32)
Create Date                     : 2009:11:10 19:27:39
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