Include only prescriptions that may require reimbursement. Claim 1 (please print) Drug Name NDC # Prescription # Date of Fill Dosage Quantity (25 mg, etc) (on receipt or call pharmacy) Prescriber’s Name (Doctor) Days Supply Form Total Charge Amt Primary Paid Amt You Paid (capsules, cream, etc) $ $ $ 2 (please print) Drug Name NDC # Prescription # Date of Fill Dosage Quantity (25 mg, etc) (on receipt or call pharmacy) Prescriber’s Name (Doctor) Days Supply Form Total Charge Amt Primary Paid Amt You Paid (capsules, cream, etc) $ $ $ Claim 3 (please print) Drug Name NDC # Prescription # Date of Fill Dosage Quantity (25 mg, etc) (on receipt or call pharmacy) Prescriber’s Name (Doctor) Days Supply Form Total Charge Amt Primary Paid Amt You Paid (capsules, cream, etc) $ $ $ Claim 4 (please print) Drug Name NDC # Prescription # Date of Fill Dosage Quantity (25 mg, etc) (on receipt or call pharmacy) Prescriber’s Name (Doctor) Days Supply Form Total Charge Amt Primary Paid Amt You Paid (capsules, etc) $ $ $ Claim 5 (please print) Drug Name NDC # Prescription # Date of Fill Dosage Quantity (25 mg, etc) (on receipt or call pharmacy) Prescriber’s Name (Doctor) Days Supply Form Total Charge Amt Primary Paid Amt You Paid (capsules, cream, etc) $ $ $ Claim 6 (please print) Drug Name NDC # Prescription # Date of Fill Dosage Quantity (25 mg, etc) (on receipt or call pharmacy) Prescriber’s Name (Doctor) Days Supply Form Total Charge Amt Primary Paid Amt You Paid (capsules, etc) $ $ $
Include only prescriptions that may require reimbursement. Claim 1 (please print) Drug Name NDC # (on receipt or call pharmacy) Prescription # Date of Fill Dosage (25 mg, etc) Quantity Prescriber’s Name (Doctor) Days Supply Form (capsules, cream, etc) Total Charge $ Amt Primary Paid $ Amt You Paid $ 2 (please print) Drug Name NDC # (on receipt or call pharmacy) Prescription # Date of Fill Dosage (25 mg, etc) Quantity Prescriber’s Name (Doctor) Days Supply Form (capsules, cream, etc) Total Charge $ Amt Primary Paid $ Amt You Paid $ Claim 3 (please print) Drug Name NDC # (on receipt or call pharmacy) Prescription # Date of Fill Dosage (25 mg, etc) Quantity Prescriber’s Name (Doctor) Days Supply Form (capsules, cream, etc) Total Charge $ Amt Primary Paid $ Amt You Paid $ Claim 4 (please print) Drug Name NDC # (on receipt or call pharmacy) Prescription # Date of Fill Dosage (25 mg, etc) Quantity Prescriber’s Name (Doctor) Days Supply Form (capsules, etc) Total Charge $ Amt Primary Paid $ Amt You Paid $ Claim 5 (please print) Drug Name NDC # (on receipt or call pharmacy) Prescription # Date of Fill Dosage (25 mg, etc) Quantity Prescriber’s Name (Doctor) Days Supply Form (capsules, cream, etc) Total Charge $ Amt Primary Paid $ Amt You Paid $ Claim 6 (please print) Drug Name NDC # (on receipt or call pharmacy) Prescription # Date of Fill Dosage (25 mg, etc) Quantity Prescriber’s Name (Doctor) Days Supply Form (capsules, etc) Total Charge $ Amt Primary Paid $ Amt You Paid $