Allergenic Extract Claim Form PDF Details

When navigating the healthcare landscape, especially for those dealing with allergies, understanding how to properly utilize the Allergenic Extract Claim Form is crucial. This form is designed for members who need to submit a claim for reimbursement for allergenic extracts. It's a key piece of documentation that ensures members are reimbursed for the expenses incurred from their treatment, but there's a catch; every section of the form must be filled out meticulously, including specifying the number of vials, or else the claim gets rejected. The form requires basic subscriber information, details about the patient, and an assertion from the member that all the information provided is correct and that the allergenic extract has been received. It goes a step further to mandate that only charges related to the allergenic extract are claimable, excluding any fees tied to the administration or office visits. On the flip side, pharmacists or physicians also have a section to complete, providing details about the treatment, including the number of vials and the cost, alongside certifying that the charges are exclusively for the allergenic extract. For a claim to be processed successfully, the completed form, together with an itemized bill from the healthcare provider, must be sent to a specified address. This underscores the importance of accurately completing the form to ensure that the reimbursement process is seamless and efficient, providing a crucial support system for individuals managing their allergy treatments.

QuestionAnswer
Form NameAllergenic Extract Claim Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesAllergenic, RX, CVSD, cvs allergenic extraxt claim form

Form Preview Example

Allergenic Extract Claim Form

MEMBER—PLEASE COMPLETE THIS SECTION

Member/Subscriber Information See your prescription drug ID card.

Important: All sections of this

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Group No.

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X

C

V

S

D

 

 

 

 

 

 

 

 

 

 

 

 

 

form must be completed, including

 

the number of vials, or the claim

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

will be rejected and returned to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the member.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member Name (First, Last)

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Information

Gender

Relationship to Plan Member

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0 Female

0 1

Self

 

 

 

 

 

 

Patient Name (First, Last)

 

 

 

 

 

 

0 Male

0 2

Spouse

Patient Date of Birth (Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0 3

Eligible Dependent

Important: I certify that the information entered on this form is correct; that the claimant is eligible for the benefit and has received the medication described. I agree the benefit payable for prescription drugs is not assignable and that any assignment or attempted assignment shall be void. I further authorize the release of all information on this form to CVS Caremark and the health plan. I have discussed this claim with my doctor, and it covers the allergenic extract only and excludes any administration or office charges.

 

 

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Signature of Member

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHARMACIST/PHYSICIAN—PLEASE COMPLETE THIS SECTION

 

 

 

 

 

 

 

 

 

 

 

 

 

Pharmacist/Physician Information

 

Date of Purchase

 

 

 

No. of Vials:

Charge per treatment for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

professional immunotherapy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

in your office.

Name of Pharmacist/Physician

 

 

 

 

 

 

 

 

 

 

No. of

 

Days’ Supply

Vial Contains

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single Antigen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

Single Dose

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Multiantigen

Charge for preparation of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Multidose

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

allergenic extract in location

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Directions

 

 

 

 

 

 

Administered by

other than your office.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nurse

 

 

 

State

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self

Total charge for allergenic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone (include area code)

 

 

 

 

 

 

 

 

 

 

 

extract only.

 

Ingredients

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I CERTIFY THE CHARGES ARE FOR THE ALLERGENIC EXTRACT ONLY, AND THE INFORMATION ON THE FORM IS CORRECT.

 

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pharmacist/Physician Signature

 

 

 

 

 

 

 

Date

 

NABP Number

INSTRUCTIONS FOR COMPLETION OF ALLERGENIC EXTRACT CLAIM FORM

1.All of the information requested must be legibly entered on the claim form. This information is required to determine whether the medication is covered under your plan.

2.This claim form is for allergenic extract reimbursement only. Physicians' professional fees are not covered under your prescription plan.

3.Provide date of purchase.

4.Attach the itemized bill from your physician or pharmacist to the form.

5.Submit the completed form to:

CVS Caremark P.O. Box 52136 Phoenix, AZ 85072-2136

05/09/12

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