Compounding Universal Claim Form – Fill Out and Use This PDF

Patient Information

Prescription Information

Universal Claim Form for a Compounded Medication©

Recognized by the International Academy of Compounding Pharmacists

PHARMACY INFORMATION

Pharmacist’s Name

Date

Pharmacist

Pharmacist’s License #

NABP#

Pharmacist’s Signature

State ID#

Name

Telephone

Name

Telephone

Information

Address

Address

City

State

Zip

City

State

Zip

Birthdate

Sex

Social Security/Subscriber I.D. No.

Birthdate

Sex

Social Security/Subscriber I.D. No.

Cardholder

Patient’s Relationship to Cardholder

Group No.

Plan No.

Employer

Employer I.D.

Patient Authorization

I hereby authorize release of information to health care providers, institutions, and /or payers that may pertain to my illness and/or treatment received. I certify that the information I have reported with regard to my insurance coverage is correct, and I have received the pharmacist care/services rendered.

Patient Signature

Date

I hereby authorize my Pharmacy (in either case, “Pharmacy”) to execute on my behalf any assignment of benefits documents required to permit my insurer to make payment directly to Pharmacy or its assigns. I understand that any amounts not paid by insurer because of deductible clauses, lack of coverage, or refusal to accept assignment of benefits shall be my responsibility.

		Patient Signature	Date
Medication Name			Price
Prescription Number	Days Supply	Date Filled
Dosage Form		Strength
Active Ingredients		Quantity Dispensed
Prescriber’s Name		DEA #

Pharmacist Authorization

I hereby certify that the above compounded medication was ordered by the stated prescriber specifically for the stated patient. This medication is not commercially available in this formulation or dosage form. The compounding was done using the highest possible standards, pure chemicals or drugs and contemporary technology. Because this prescription medication is compounded and not manufactured, an NDC number is not required for reimburesement.

Pharmacist Signature

Date

If you have difficulty in submitting this form or receiving payment from your insurance company,

please contact us, your employee benefits manager, or the State Insurance Commissioner at

Form Number USC0001

© International Academy of Compounding Pharmacists