Knowing how the Allergenic Extract Claim Form works before you start filling it out helps avoid the most common submission errors. The form is divided into two main sections: one completed by the member or subscriber, and one completed by the dispensing pharmacist or physician.
The member section collects your full name, mailing address, and plan identification number. If you are filing on behalf of a dependent, include the patient's information as well. You must certify that the allergenic extract was received and that all information provided is accurate. Only charges for the allergenic extract itself are eligible. Fees for office visits or injection administration must be excluded from the claim total.
Your dispensing pharmacist or physician completes the second section by listing the number of vials dispensed, the cost per vial, and the total charge. They must sign the form to certify that all charges are exclusively for the allergenic extract. An unsigned or incomplete provider section is one of the most common reasons reimbursement claims are delayed or denied.
Attach an itemized bill from your provider to the completed form before mailing. The bill must show the date of service and the exact charge for the allergenic extract. Send both documents to the address printed on the form. If you handle other healthcare reimbursements, the Reimbursement Claim Form and the FSA Medical Claim Form are useful templates for related expenses.
| Question | Answer |
|---|---|
| Form Name | Allergenic Extract Claim Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Allergenic, RX, CVSD, cvs allergenic extraxt claim form |