Get Universal Claim Form Pharmacy

Filling out the Universal Claim Form Pharmacy online can seem daunting, but with careful guidance, it becomes a straightforward process. This guide will walk you through each section of the form, providing clear instructions to help ensure your submission is accurate and complete.

Follow the steps to successfully complete your claim form.

1. Click 'Get Form' button to access the Universal Claim Form Pharmacy and open it in your preferred editor.
2. Begin by entering the pharmacy information. Provide the name of the pharmacy, which is 'Park Pharmacy & Compounding Center,' along with the pharmacist's name, Dennis Saadeh. Fill in the pharmacy's address, including the street, city, state, and zip code, as well as the NABP number and phone number.
3. Next, complete the cardholder information section. Enter the cardholder's name, phone number, and address. Be sure to include the city, state, and zip code. Additionally, provide the cardholder's birthdate and Social Security Number or Subscriber ID.
4. Then, input the patient information. This requires the patient's name, phone number, address, and similar demographics as the cardholder, including city, state, and zip code, along with their birthdate and SSN or Subscriber ID.
5. Proceed to the prescription information section. Fill out the medication name, prescription number, cost, days' supply, date filled, dosage form, and strength. Ensure you also list the active ingredient and the quantity dispensed.
6. Finally, document the prescriber's DEA number, then review all entries for accuracy. Once satisfied, you can save your changes, download a copy of your completed form, print it, or share it as required.

Start completing your Universal Claim Form Pharmacy online today!