PAI PRESCRIPTION CLAIM FORM For Payment Directly To Patient
EMPLOYER_________________________________INSURANCE CARRIER____________________________ Insured/Cardholder Name:_____________________________________________________________________ Address: ___________________________________________________________________
(Street)
________________________________________________________________________________________________________
(City) (State) (Zip)
Claimant/Patient Name: ____________________________________________________________________________________________________________ Insured Identification Number: ___________________________Patient Suffix: __________________________
(person code found in front of name)
Patient’s Date of Birth _____\____\____
Sex: Male ________Female_______
Please attach copies of your prescription receipt(s)or a pharmacy printout to this form of processing. If you do not have such documentation, please have your pharmacist complete the remaining portion of this form. If no receipt(s) or printout is attached, all sections must be completed and the pharmacist’s signature is required. Handwritten information provided without pharmacist’s signature will be returned. PRESCRIPTION #1: Date filled ____\____\____
Rx # NEW REFILL
(circle one)
Drug Name: __________________________________________
QUANTITY DAYS SUPPLY NATIONAL DRUG CODE Prescriber
DAW
Prescription Price Including tax (if applicable) $ _____________ PRESCRIPTION #2: Date filled ____\____\____
Rx # NEW REFILL
(circle one)
Drug Name: ___________________________________________
QUANTITY DAYS SUPPLY NATIONAL DRUG CODE Prescriber
DAW
Prescription Price Including tax (if applicable) $ _____________ PHARMACY NAME: _____________________________________ NABP#: ________________________
PHARMACIST’S SIGNATURE _________________________________________________________________
Mail To: PHARMACY ASSOCIATES, INC. P.O. Box 23007 LITTLE ROCK, ARKANSAS 72221-3007