CLM08_04 Rx Claim Reimbursement Form 2010 Form2010 CLM08 04
User Manual: CLM08_04 RxClaimReimbursementForm2010
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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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