Fillable Benets Verication Request Form

Fill Online, Printable, Fillable, Blank Benets Verication Request Form Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Benets Verication Request Form

On average this form takes 16 minutes to complete

The Benets Verication Request Form form is 2 pages long and contains:

  • 0 signatures
  • 6 check-boxes
  • 62 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
IMPORTANT: Prescriber gives Biologics, Inc. express permission to use his/her NPI number included herein for the purpose of identifying the referring
prescriber to the authorized pharmacy benefits manager and/or payer. Biologics, Inc. accepts no liability regarding any decisions concerning claims, coverage
or payment, which are made in the sole discretion of the health plan administrators and insurers. Biologics, Inc. makes no assurance that any prescribed drug
will be covered or reimbursed at any specific level under any patient’s insurance plan, or that any specific pharmacy will provide the prescribed drug.
Paragard® is a registered trademark, and Paragard Benefits Verification
SM
is a service mark of CooperSurgical, Inc.
© 2020 CooperSurgical, Inc.
C-US-PAR-000023 August 2020
PHONE: 1-888-275-8596
FAX: 1-855-215-5315
If patient is a minor and is signing the authorization on the following page on her own behalf, please arm that:
This patient has the capacity to consent to treatment with Paragard under the law of the state in which I practice (and the consent of a parent or guardian is not required), or
This patient’s parent or guardian has consented to the patient’s treatment with Paragard, as required by applicable state law.
Patient Name:
Address:
City: State:
Zip:
Home Phone:
Cell Phone:
Date of Birth:
See Attached Demographic Sheet
PATIENT INFORMATION
Primary
Insurance:
City: State:
Plan #:
Group #:
Phone #:
Subscriber Name (First/Last):
ID #:
Employer:
Secondary
Insurance:
City: State:
Plan #:
Group #:
Phone #:
Subscriber Name (First/Last):
ID #:
Employer:
Rx Card
(PRM):
PBM BIN:
City: State:
Group #:
Phone #:
Subscriber Name (First/Last):
ID #:
Employer:
INSURANCE INFORMATION (Please attach copies of front & back of cards)
PAR T380A – QTY 1/Paragard (intrauterine copper
contraceptive) to be inserted one time by prescriber.
PRESCRIPTION INFORMATION
Z30.430: Encounter for insertion of
intrauterine contraceptive device
Other: Please Specify
DIAGNOSTIC INFORMATION (ICD-10 Code)
Patient Signature: Date: / /
Prescriber Signature: Date: / /
For ARNP, NP, and PA, collaborative physician agreement is with: Date: / /
Prescriber Name:
State Lic #:
NPI #: Specialty:
Facility Name:
Address:
City:
State:
Zip:
Ship To Address (Required):
City: State: Zip:
Prescriber’s Phone:
Prescriber’s Fax:
PREFERRED COMMUNICATION
Oce Contact Name:
Direct Phone Number:
Direct Email Address:
Direct Fax:
PRESCRIBER INFORMATION
Benefits Verification Request Form
If you have any questions, please call 1-888-275-8596.
I understand that my signature will be used as an approval allowing the Specialty Pharmacy to dispense Paragard. If I have a financial responsibility for obtaining Paragard,
I understand that Biologics will contact me prior to the dispense.
PHONE: 1-888-275-8596
FAX: 1-855-215-5315
In accordance with the Health Insurance Portability and Accountability Act of 1996 and related federal regulations
and rules (“HIPAA”), this Authorization authorizes my healthcare provider, health plan, and my pharmacy to disclose my
health and personal information to CooperSurgical, Inc. and it’s agent, Biologics, Inc. (and its aliates, and their respective
representatives, and agents [collectively, “Biologics”]) in furtherance of the below-stated authorized purposes. The “Paragard”
program is operated by Biologics on behalf of CooperSurgical, Inc.
Authorized Purposes
I understand that the Paragard Program and Biologics will receive my health and personal information, which may include
my name, address, patient insurance identification number, date of birth and other information necessary to obtain health
insurance benefit verification for the following purposes: (1) the administration of CooperSurgical’s Paragard Program;
(2) to conduct benefit verification determining insurance reimbursement and coverage of Paragard; (3) to contact me to
discuss any relevant co-pay; (4) bill the insurance company; (5) bill the applicable co-pay; (6) ship the unit to my healthcare
provider; (7) to contact me by telephone in furtherance of conducting benefits verifications investigations and/or specialty
pharmacy dispense; and (8) if I choose to self-pay for Paragard, to invoice me and to otherwise contact me to collect
payment for the Paragard unit.
By signing the following form, I understand:
1. Once my healthcare provider gives Biologics and the Paragard Program information about me based on this
Authorization, my medical and health information may be subject to redisclosure and is no longer protected by
federal privacy regulations.
I further understand and agree that Biologics and the Paragard Program may retain my medical and health information
as disclosed under this Authorization after this Authorization expires.
I also understand that in the event of an audit, and for purposes of such an audit, some information may also be disclosed
to CooperSurgical, Inc., the manufacturer of Paragard, or its aliates after this Authorization has expired, so long as
the audit is for a period of time when this Authorization was in eect.
2. I may refuse to sign this Authorization form and that, unless allowed by law, my refusal to sign will not aect my ability
to obtain treatment from my healthcare provider; or to seek payment; or my eligibility for insurance benefits.
3. I may revoke my authorization at any time by providing a written notice of same to my healthcare provider, health plan
and/or pharmacy that refers to (or with a copy of) this Authorization form, or to Biologics/the Paragard Program at 11800
Weston Parkway, Cary, NC 27513. I understand that if I revoke this Authorization, it will not aect prior disclosures made to
Biologics and any use of such information by Biologics in reliance of this Authorization. I understand that I have the right
to receive a copy of this Authorization.
4. This Authorization shall expire one year after I have signed it, or upon revocation, whichever is earlier.
Signature of Patient or Legal Personal Representative: Date: / /
Name of Patient or Legal Personal Representative:
(If Applicable) Description of Personal Representative’s Authority to Sign for Patient:
Paragard® is a registered trademark, and Paragard Benefits Verification
SM
is a service mark of CooperSurgical, Inc.
Patient Authorization for Benefits Verification
© 2020 CooperSurgical, Inc.
C-US-PAR-000023 August 2020
Please see Important Safety Information and
Full Prescribing Information for Paragard at Paragard.com.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Benets Verication Request Form

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 October 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document