Allergenic Extract Claim Form – Fill Out and Use This PDF

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.

R

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.

X

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