Allergenic Extract Claim Form PDF Details

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.

Member Section

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.

Pharmacist or Physician Section

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.

Submission Requirements

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.

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

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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.

 

 

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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

How to Edit Allergenic Extract Claim Form Online for Free

Follow these steps to fill out and submit the allergenic extract claim form correctly and avoid delays in reimbursement.

Step 1: Gather your documents. Before you begin, collect your health plan ID card, an itemized bill from your pharmacist or physician, and the exact dates of service for the allergenic extract you received.

Step 2: Complete the member section. Enter your full name, address, and subscriber ID number. Include the patient's information if you are submitting on behalf of a dependent. Confirm that the allergenic extract was received and that all charges listed are exclusively for the extract. Do not include fees for office visits or injection administration.

Step 3: Have your provider complete their section. Ask your dispensing pharmacist or physician to fill in the number of vials dispensed, the cost per vial, and the total charge. Their signature is required to certify that only allergenic extract charges are included.

Step 4: Attach the itemized bill. Clip the itemized bill from your provider to the completed form. The bill must show the date of service and the exact charge for the allergenic extract.

Step 5: Mail your submission. Send the completed form and itemized bill to the address printed on the form or provided by your plan. Keep a copy of everything for your records. Processing typically takes up to 30 days. For other healthcare expense claims, see the medical claim form or the Healthscope medical claim form.

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