Get Remittance Advice Form

Filling out the Remittance Advice Form online can streamline the payment setup or change process for pharmacies and vendors. This guide will provide you with clear and detailed instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to accurately fill out the Remittance Advice Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter the pharmacy name in the designated field at the top of the form. This identifies the pharmacy for which the payment setup or change is being requested.
3. Indicate the action requested by selecting the appropriate option from the dropdown menu. This could be a new setup or a change to existing information.
4. Fill in the effective date when the requested action should take place. This is crucial for processing your request in a timely manner.
5. Provide the chain code or NCPDP number in the specified field. This number helps in identifying the pharmacy in the system.
6. Fill in the federal tax ID number as required for compliance and record-keeping purposes.
7. Select any relevant options that apply to your request by checking the corresponding boxes. These options may include specific pharmacy networks such as Caremark or Aetna.
8. Complete the pharmacy details, including attention name, street address, city, state, zip code, and contact information. Make sure all fields are filled accurately.
9. Provide the vendor information in the following section, including vendor name, attention contact, and street address. Ensure all details are accurate.
10. Fill out the vendor approval contact details, including phone number and email address to ensure proper communication.
11. Once all sections are filled out, review your entries for accuracy. Ensure all required fields are completed to avoid delays in processing.
12. Finally, save your changes, and you may choose to download, print, or share the form as needed for your records.

Complete your Remittance Advice Form online today and ensure a smooth payment process.