Prescription Claim Reimbursement Form

User Manual: Prescription-Claim-Reimbursement-Form

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PHARMACY SERVICES
PRESCRIPTION DRUG CLAIM FORM
1. This form is to be used to claim prescription drug benefits provided to eligible GuildNet Gold Plus FIDA
Plan participants.
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 participant. In addition, use a separate form for each pharmacy
serving the participant.
5. Send the form and receipts to:
GuildNet Gold Plus FIDA Plan
PO Box 1520 JAF Station
New York, NY 10116-1520

A. SUBSCRIBER INFORMATION

FOR OFFICE USE

ID #

Claim #

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

State
Male

Female

ZIP

Participant ID#

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

Please see next page.

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#

New

Refill

Qty Dispensed

Strength

Days Supply

Rx Cost
$

Prescriber Name

Prescriber State License #

PRESCRIPTION INFORMATION

Name of Medication

Rx #

Qty Dispensed

Days Supply

Date dispensed: ____/____/______
NDC#

New

Refill

Prescriber Name

Strength

Prescriber State License #

PRESCRIPTION INFORMATION

Name of Medication

Rx #

Qty Dispensed

Days Supply

Rx Cost
$

Date dispensed: ____/____/______
NDC#
Prescriber Name

New

Refill

Strength

Prescriber State License #

Rx Cost
$

GuildNet Gold Plus FIDA Plan is a managed care plan that contracts with both Medicare and New York State
Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully
Integrated Duals Advantage (FIDA) Program. Enrollment in GuildNet Gold Plus FIDA Plan depends on
contract renewal.
Benefits, List of Covered Drugs, and pharmacy and provider networks may change from time to time
throughout the year and on January 1 of each year.
H0811_GN144_Rx Reimbursement Form_GN Approved

You can get this information for free in other languages. Call 1-800-815-0000 (TTY 1-800-662-1220), Monday
through Sunday 8am to 8pm. The call is free.
Usted puede obtener esta información en otros idiomas gratis. Llame al 1-800-815-0000 o TTY/TDD al 1-800662-1220, de lunes a domingo de 8am a 8pm. La llamada es gratis.
Queste informazioni sono disponibili gratuitamente in altre lingue. Chiamare il numero verde 1-800-815-0000 o
1-800-662-1220 mediante un telefono testuale per non udenti (TTY/TDD), da lunedì a domenica, dalle 8 alle
20. La chiamata è gratuita.
您可以免費獲得本信息的其他語言版本。請撥打 1-800-815-0000 或聽障／語障人士專線 (TTY/TDD) 1800-662-1220，星期一至星期日上午 8 時至晚上 8 時。撥打該電話免費。
Вы можете бесплатно получить эту информацию на других языках. Позвоните по телефону 1-800-8150000 и TTY/TDD 1-800-662-1220. Служба работает с понедельника по воскресенье с 08:00 до 20:00 ч.
Звонок бесплатный.
Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang. Rele nimewo 1-800-815-0000 oswa TTY/TDD 1-800662-1220, lendi jiska dimanch, depi 8am jiska 8pm. Koutfil la gratis.
다른 언어로 작성된 이 정보를 무료로 얻으실 수 있습니다. 월요일 - 일요일 오전 8시부터 오후 8시
사이에 1-800-815-0000번이나 TTY/TDD 1-800-662-1220번으로 전화주세요. 통화는 무료입니다.
The State of New York has created a participant ombudsman program called the Independent Consumer
Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by
GuildNet Gold Plus FIDA Plan. ICAN may be reached toll-free at 1-844-614-8800 or online at icannys.org.
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