Supply Form for Diabetic Supplies - PDF

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Supply Form for Diabetic Supplies - PDF Powered By Docstoc
					 Cardholder Name (Last, First, MI)            Cardholder’s Relationship to Patient:
                                                 Self     Spouse    Dependent
 Patient Name (if different than              Date of Birth Gender      Cardholder or Patient ID #:
                                                             M F
    Check if new address

 City/State________________________ Zip Code______________ Daytime Telephone ( _ )_________

 Health Plan Name                                                         Group Number

 Primary Insurance Information:
 Is Medicare Part D the Cardholder/Patient primary coverage            Yes      No
 If NO, please attach an explanation of benefits from the Primary Carrier.
PLEASE SIGN AND DATE HERE: I certify that all information provided is correct and that the
prescription(s) submitted are for me. I have received the medication, and I authorize release of all information
on this claim to Express Scripts, Inc. and GHI. 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
                                                                                          Number of receipts
Cardholder’s Signature and Date                                                           attached:____
 In order to process your request, all prescription claims must have prescription receipts/labels
 which include the following:
 • Cardholder/Patient Name         • Pharmacy Name/Address • Date Filled
 • Drug Name, Strength and NDC • Prescription Number          •Quantity    • Days Supply • Price

 Please tape prescription receipts to separate piece of paper.
 CASH REGISTER RECEIPTS ARE NOT ACCEPTABLE (with the exception of diabetic supplies)

 Is claim for Diabetic Supplies?     Yes       No
 If Yes, please ask your pharmacist for assistance in determining which supplies are covered under your
 Medicare Part D plan.
 Receipts must include:
                    • Cardholder/Patient Name • Pharmacy Name/Address • Date Filled
                 • Type of Insulin and/or Type of Supply • Quantity •Days Supply • Price
 Cash register receipts are acceptable for diabetic supplies, but the Pharmacist’s Signature is required if
 any information is handwritten.

 Is claim for allergy serum or vaccination?     yes     no
 If yes, please supply type or additional information:_________________________________________
                                                                            For ESI use
                                        Please return this claim to:
                                        Express Scripts, Inc
                                        P.O. Box 66752
                                        St. Louis, MO 63166-6752
                                        ATTN: MED-D Accounts

                  CLAIM FORM ON REVERSE SIDE.
Cardholder/Patient Information (please complete a separate claim for form each insured member)
   1. Print Cardholder name (last, first, middle initial).
   2. Indicate Cardholder’s relationship to the Patient.
   3. Print Patient (if different than Cardholder) name (last, first, middle initial).
   4. Print Cardholder/Patient date of birth.
   5. Circle the correct letter to indicate if Cardholder/Patient is male or female.
   6. Print Cardholder/Patient ID number (found on Plan Identification Card).
   7. Print Cardholder/Patient mailing address and daytime telephone number. Check box if this is a
       new address.
   8. Indicate Cardholder/Patient Health Plan Name and group number (found on Plan Identification
   9. Indicate if Medicare Part D is Cardholder/Patient Primary coverage. If Cardholder/Patient has
       other primary coverage, please attach an explanation of those benefits.
   10. IMPORTANT - CLAIM FORM MUST BE SIGNED. Unsigned claim forms cannot be
   11. Indicate number of receipts submitted for reimbursement consideration.
   12. Indicate if claim is for diabetic supply. If yes, please provide drug detail. Ask your pharmacist
       for assistance in determining which supplies are covered under your Medicare Part D plan.
   13. Indicate if claim is for allergy serum or vaccination. If yes, please provide drug detail.

In order for your request to be processed, each submission must include prescription receipts or a patient
history printout from your pharmacy including:

                     • Pharmacy name and address                 • Quantity
                     • Date filled                               • Days Supply
                     • Drug name, strength and NDC number        • Price
                     • Rx Number                                 • Patient’s name

Please note that claims received missing any of the above information may be returned or payment may
be denied.

Please DO NOT staple or glue prescription receipts. It is preferable to have receipts unattached or
taped to a separate piece of paper.

If you have any questions, please call Express Scripts Customer Service Department at 1-800-585-
5786, 24 hours a day, 7 days a week. TDD/TTY users call 1-800-899-2114.

H5528/H3340/S5966 110609.1 4/1/2007                                 CMSTLC.CLG         03/02/06

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