Form Lara Hid 220 – Fill Out and Use This PDF

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Form Lara Hid 220 PDF Details

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Form Name	Form Lara Hid 220
Form Length	1 pages
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Avg. time to fill out	15 sec
Other names	cis_fhs_bhser_m apsclaimform4 09_316533_7 what is maps claim form in michigan

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LARA/ HI D-220 (02/ 14)

State of Michigan

Department of Licensing and Regulatory Affairs

Bureau of Health Care Services

Michigan Aut omat ed Prescript ion Syst em ( MAPS)

P.O. Box 30454, Lansing, Michigan 48909

Telephone: (517) 373-1737 Fax: (517) 241-5072 E-Mail: BHCSMAPSI nfo@michigan.gov

Website: www.michigan.gov/ mimapsinfo

MAPS CLAI M FORM

Authority: P.A. 231 of 2001

Board of Pharmacy Rule 338.3162d requires this form to be completed for every controlled substance that is dispensed, and mailed or delivered to MAPS no later than 7 calendar days after the date the controlled substance has been dispensed.

Dispenser I nformat ion ( Please Print )

DEA Number	Dispenser’s First Name			Middle Name	Last Name

Street Address			City			State	Zip Code

Telephone Number with Area Code		Email Address

Pat ient I nformat ion (I f veterinary patient – use pet owner information)

Customer I D (Driver’s License or State I D Number)

Patient’s First Name (human)

Last Name

Street Address

City

State

Zip Code

Date of Birth (human)

Sex

Species Code

Male

Female

Unknown

Human

Veterinary Patient

Cont rolled Subst ance Dispensed

I ssued Date

Filled Date

Prescriber DEA Number

NDC Number (Must be eleven digits)

Drug Name

-–

Quantity

Refill Number

Transmission Form

Written Prescription

Telephone

Telephone Emergency

Fax

Days Supply

Authorized Refills

Mode of Payment

Private Pay

Medicaid

Medicare

Commercial I nsurance

RX Number

Major Medical

Worker’s Comp

I ndian Nations

Other