Get Medco Provider Verification Form

Filling out the Medco Provider Verification Form online is an essential step for healthcare providers seeking to verify their credentials. This guide provides clear instructions on each section of the form to ensure a smooth and accurate submission process.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section A, provide your provider information, including your NPI number, Medco Account number (if applicable), NCPDP number, and the pharmacy name or dispensing prescriber name. Remember to include the physical street address, city, state, zip code, pharmacy phone number, and secure fax number. Be sure to print clearly or type for accuracy.
3. Continue to Section B to indicate the professional practice settings. Fill out the anticipated percentage of prescriptions for each setting, ensuring that all entries total 100%. Include categories such as retail/community, LTC facility, mail order, and others as applicable.
4. In Section C, enter your business information, including DEA number, state board of pharmacy license number, Medicare Part B supplier ID, and federal tax ID. Specify the effective date and list all Medicaid numbers issued by each state if applicable.
5. Complete the remaining fields in Section C, continuing to provide details about software vendors, insurance carriers, hours of operation, and any other relevant pharmacy information. This information is crucial for accurate records.
6. Move to Section D for the attestation. Answer whether any disciplinary actions have been taken or are pending against you or your staff within the last five years. Follow the instructions to provide necessary documentation.
7. List all owners' names, titles, and dates of ownership in the designated area. Ensure this information is accurate as it must match official records.
8. Finally, complete the signature field, print your name and title, and check for any missing information in all sections. Once completed, you can save changes, download the form, print it, or share it as necessary.

Start filling out your Medco Provider Verification Form online now to ensure proper verification of your provider credentials.