Prescription Drug Claim Form
User Manual: Prescription-Drug-Claim-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 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 PO Box 1520 JAF Station New York, NY 10116-1520 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_GN332_Rx Reimbursement Form web_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 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 speakers. 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.
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