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Get Cvs Caremark Allergenic Extract Form

RX CVSD Member ID Member Name First Last Street Address City State Patient Information Gender 0 Female 0 Male Patient Name First Last Patient Date of Birth Month/Day/Year Zip Relationship to Plan Member 0 1 Self 0 2 Spouse 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. Allergenic Extract Claim Form MEMBER PLEASE COMPLETE THIS SECTION Member/Subscriber Information See your prescription drug ID card. Group No* Important All sections of this form must be completed including the number of vials or the claim will be rejected and returned to the member. X Signature of Member Date PHARMACIST/PHYSICIAN PLEASE COMPLETE THIS SECTION Pharmacist/Physician Information Date of Purchase Name of Pharmacist/Physician No* of Treatments / No* of Vials Days Supply Vial Contains Single Antigen Multiantigen Charge for preparation of Single Dose Multidose Directions Administered by Physician Nurse Self Telephone include area code Charge per treatment for professional immunotherapy in your office. Ingredients other than your office. Total charge for allergenic extract only. I CERTIFY THE CHARGES ARE FOR THE ALLERGENIC EXTRACT ONLY AND THE INFORMATION ON THE FORM IS CORRECT. 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. Allergenic Extract Claim Form MEMBER PLEASE COMPLETE THIS SECTION Member/Subscriber Information See your prescription drug ID card. Group No* Important All sections of this form must be completed including the number of vials or the claim will be rejected and returned to the member. X Signature of Member Date PHARMACIST/PHYSICIAN PLEASE COMPLETE THIS SECTION Pharmacist/Physician Information Date of Purchase Name of Pharmacist/Physician No* of Treatments / No* of Vials Days Supply Vial Contains Single Antigen Multiantigen Charge for preparation of Single Dose Multidose Directions Administered by Physician Nurse Self Telephone include area code Charge per treatment for professional immunotherapy in your office. Ingredients other than your office. Total charge for allergenic extract only. I CERTIFY THE CHARGES ARE FOR THE ALLERGENIC EXTRACT ONLY AND THE INFORMATION ON THE FORM IS CORRECT.

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