Prescription Drug Benefit Manual Chapter 9 - Compliance Program Guidelines and Medicare Managed Care Manual Chapter 21 – Compliance Program Guidelines
T2491 v.03 11.06.2017. Page . 1. of . 8. 01-CA9674 H. SETTLEMENT REGISTRATION/CLAIM FORM. Auto Airbag Settlement for
Denplan Corporate claim form To help us settle your claim quickly please complete all sections as accurately as you can. ... Denplan Corporate, Denplan Ltd,
OTHER COVERAGE. Statement of Actual Services – OR –. Request for Predetermination / Preauthorization ... 40. Is Treatment for Orthodontics? Provider's Office. Hospital. ECF. Other. 45. Treatment Resulting from (Check applicable box). 47. Auto Acciden
Payee NRIC: Bank Account No:: Notification of payment will be sent to this email address. Important Notice: The Company shall (i) be discharged from all liability
1027/MENKES/SK/IX/2004 good prescription writing form consist of; doctor's name,. SIP, address .... (obat narkotika, psikotropika dan keras), dimana ... Untuk obat narkotika hanya berlaku untuk satu kota provinsi. Format inscriptio suatu resep dari r
Georgia Prescription Drug Monitoring Program (PDMP) begins allowing access to Rx data. On July 26. th, the switch was finally flipped to turn on access for
Denplan claim form To help us settle ... Denplan Corporate, Denplan Court, ... please make sure this is clearly stated on this claim form and your itemised receipt
Aetna International Claim Form . Please submit this completed claim form with itemized bills and receipts. A separate claim form is needed for each family
CITY OF PHILADELPHIA. RISK MANAGEMENT DIVISION - CLAIMS UNIT. 1515 ARCH STREET ... DATE OF BIRTH: SOCIAL SECURITY NUMBER: DATE AND TIME OF THE ACCIDENT/INCIDENT: ... THE CITY WILL PROVIDE AN AFFIDAVIT OF NO INSURANCE TO BE NOTARIZED. AFTER SUBMITTING
Zurich Australian Insurance Limited ABN 13 000 296 640, AFS Licence No. 232507. 5 Blue Street North Sydney NSW 2060. General Claim Form – Page 1 of 4. General. Claim form. ZU07392 - V3 03/14 - CW. AN-006478-2012. All relevant sections are to be answe
or your tenant, or related to you, give full details werknemer, ‘n huurder of ‘n familielied is, meld besonderhede Claim If a claim has been, or is being
Download GLOBE GADGET CARE. CLAIM FORM. Important Information. 1. In order to submit your claim, please complete the relevant sections. This first page must be ...
Date of birth DDDDDDDD . Dental claim form . Bu Please ensure that you complete this form fully and return it to us with copies or uploads of your original receipts
National Health Insurance Company – Daman ... Reimbursement Claim Form ... healthcare services provided to me during the period of my insurance coverage with Daman
PLEASE READ BEFORE COMPLETING THE CLAIM FORM ‘ All claim forms should be submitted ... completed this form please post it to: Denplan Corporate Denplan Court
Prescription Drug Use Among Midlife and Older Americans Published January 2005
MEDICAL EXPENSE REIMBURSEMENT ACCOUNT CLAIM ... If you are a member of a group plan that ... Complete and sign the Medical Expense Reimbursement Account Claim form
Pages 2-5 - Accident Medical Expense Claim Form Pages 6-8 ... ZURICH AMERICAN INSURANCE COMPANY PROOF OF CLAIM – ACCIDENT MEDICAL EXPENSE
Denplan Corporate Claim Form PLEASE FILL IN ALL DETAILS AND USE BLOCK CAPITALS THROUGHOUT. Title: First Name: Address: Tel No: If YES give details
prevention Tactics The Elderly and Prescription Drug Misuse and Abuse By Belinda Basca P rescription drug use is on the rise in the United States
BENEFIT TYPE: PLEASE ENCLOSE THE FOLLOWING ITEMS WITH THE ABOVE CLAIM FORM: Prescription Drugs All itemized Prescription drug receipts from your pharmacist
PICA B. PLACE OF SERVICE 1a. INSURED’S I.D. NUMBER (For Program in Item 1) 4. INSURED’S NAME (Last Name, First Name, Middle Initial) 7. INSURED’S ADDRESS (No
CONTINENTAL AMERICAN INSURANCE COMPANY CLAIM FORM Post Office Box 427 Email: [email protected] . Columbia, South Carolina 29202 Phone (800)433-3036 Fax (803)799-7737
Prescription Drug Claim Form Each Pharmacy Receipt Must Show: • Participant Name • Prescription Number • Pharmacy Name and Address or NABP Number
• Drug Name/Strength or NDC Number • Metric Quantity/Days Supply • Dispense as written (DAW), if applicable
• Doctor’s Name or DEA Number • Purchase Date • Total Charge
The submission of this claim form, for you or any of your dependents, authorizes the release of all information to applicable health care providers and all others involved in filling the prescriptions or processing the claims submitted.
PLEASE COMPLETE SECTIONS 1 THROUGH 4. INCLUDE RECEIPTS BEFORE MAILING.
1
SUBSCRIBER INFORMATION
2
PARTICIPANT INFORMATION
(Use a separate claim form for each covered member of the family) Participant’s Last Name
Primary Participant ID# (required)
Company Employee Number (if appropriate)
Participant’s First Name
Middle Initial
Plan Sponsor
Participant’s Birthdate
Gender:
Last Name
Month Day
Number of Receipts submitted: ______
Year
Male
Female
First Name
Middle Initial
Participant’s Relationship to Card Holder: Self Spouse Widowed Full-time Student
Mailing Address – Street
Apt.
Was this prescription obtained while traveling/residing outside the United States? Check one: Yes No
City
State
Zip Code
Daughter Son Sponsored Dependent/Other
COB (Coordination of Benefits) Is the medicine covered under any other group insurance? Yes No If yes, is other coverage: Primary Secondary If other coverage is Primary, include the explanation of benefits (EOB) with this form. Name of Insurance Company ID#
3 Reason for claim submission or special notes: _____________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ IMPORTANT! A SIGNATURE IS REQUIRED IN BOTH A AND B 4 FRAUD PREVENTION REGULATION: Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
A.
Signature of Plan Participant
Date
RELEASE OF INFORMATION: I certify that I (or my eligible dependent) have received the medicine described herein and that the plan participant named is eligible for prescription benefits. I also certify that the medicine received is not for treatment of an on-the-job injury. I have indicated in the COB box above if there is primary prescription drug coverage under another medical plan. I authorize release of all information pertaining to this claim to Caremark, the prescription benefit manager; insurance underwriter; sponsor; policyholder; and/or employer. I certify that all the information entered on this form is correct.
B.
Signature of Plan Participant
Date
PLEASE MAIL THIS FORM AND ALL ORIGINAL PRESCRIPTION RECEIPTS TO: CAREMARK INC. ATTN: CLAIMS DEPARTMENT P.O. BOX 52196 WEB CLAIM-CCF01-1007 PHOENIX, AZ 85072-2196
