This prescription was covered by a
Medic
are Part D
manufacturer patient assistance program
Prescription
Claim
F
orm
Important!
*
Always
allo
w
up
t
o 30 da
ys
fr
om
the
time
y
ou
receive
the
response
t
o
allo
w
for mail
time
plus
claims
pr
oc
essing
.
*
Keep
a copy
of
all
documents
submitt
ed
for
y
our
r
ec
or
ds
.
*
D
o
not
staple or
tape
receipts
or attachments
t
o
this
fr
om.
STEP
1
Card
H
older/P
a
tien
t
Information
T
his section
must
be
fully
completed
t
o
ensure proper
r
eimbursemen
t
of
y
our claim.
Card Holder
Inf
orma
tion
Identification
Number
(r
ef
er
t
o y
our
prescription card)
Group
No./Group Name
Name
(Last
Name)
(First
Name) (MI)
A
ddr
ess
City
Sta
t
e
Z
ip
P
a
tien
t
Information-Use
a separa
t
e
claim
f
orm
for
each
pa
tien
t
.
Name
(Last
Name)
(First
Name)
(MI)
Da
t
e
of
Birth
Male Female
Phone
Number
Relationship
t
o Primary
member
Member
S
pouse
C
hild
O
ther
O
ther
Insurance
Inf
orma
tion
COB
(Coordination of
B
enefits)
A
r
e
any
of
these
medicines
being
taken
f
or an
on-the-job injury? Yes
I
s
the
medicine
covered
under
any
other
group insurance? Yes
If
y
es
,
is
other
c
o
v
erage:
P
rimar
y
S
ec
ondary
If
other
c
o
v
erage
is
P
rimar
y, include
the
e
xplana
tion
of
benefits
(EOB)
with
this
f
orm.
Name
of
Insur
anc
e
C
ompan
y
ID#
N
o
N
o
Important!
A
signature
is
REQUIRED
NO
TICE
A
n
y
person
who
kno
wingly
and
with
in
t
en
t t
o
defraud,
injur
e
, or
deceive
any
insurance company,
submits
a
claim
or applic
a
tion
c
on
taining
any
ma
t
erially
false, deceptive, incomplete
or
misleading information pertaining
to
such
claim
may
be
c
ommitting
a
fr
audulen
t
insur
anc
e
ac
t
which
is a
crime and may
subjec
t
such person
t
o
criminal
or
civil
penalties,
including
fines,
denial
of
benefits,
and/or
imprisonmen
t
.
I certify
that
I (or my eligible dependent) have received the medicine described herein. I certify
that
I have read and understood this
f
orm,
and
that
all the information
en
t
ered
on
this
f
orm
is
true
and
c
orr
ec
t
.
X
S
igna
tur
e
of
Plan
P
ar
ticipan
t
D
at
e
(
O
ver)
Save to Disk
Save As...
Reset
Save to Disk
Save As...
STEP
2
S
ubmission
Requiremen
ts:
Y
ou
MUST
include
all
original
pharmacy
receipts
in
order
for
y
our claim
t
o
pr
oc
ess
.
Cash
r
egister
receipts
will
only
be
ac
c
ept
ed
for
diabetic
supplies
.
T
he
minimum information
that
must
be
included on
y
our
pharmacy receipts
is
listed belo
w
:
Patient Name
Prescription
Number
Medicine
NDC
number
Date of
F
ill
Metric
Q
uan
tit
y
T
otal
C
har
ge
• Days Supply for your prescription (you
need to ask your pharmacist for
this
“Day
S
upply
inf
ormation)
Pharmacy Name and
A
ddr
ess or Pharmacy
NABP
Number
A
v
alid
P
r
escribing
Ph
ysician
s
NPI
(Na
tional
P
r
o
vider
I
den
tific
a
tion)
number
is
r
equir
ed
,
please
pr
o
vide:
Additional
C
omments
STEP
3
Mailing
Instruc
tions:
Mail
t
o
:
C
VS
Car
emark
P.O. Box
52066
Phoenix,
A
Z
85072-2066
IMPORTANT REMINDER
T
o avoid having
t
o
submit
a
paper
claim
f
orm:
Always have your card available
at time of
pur
chase.
Always use pharmacies within your
net
w
ork
.
Use medication from your formulary
list.
If
problems are encountered at the
pharmacy, call the number on the back of your
c
ard
.
15071-MED_D-0912
Save to Disk
Save As...
Save to Disk
Save As...
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome