Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Fill in the cardholder information. Start with the cardholder’s ID number, group or employer name and number, followed by their full name, birthdate, address, and phone number.
3. Provide the patient information. Enter the patient's name, gender, and relationship to the cardholder, along with the patient’s birthdate.
4. Indicate the reason for the request. Select from the listed options such as coordination of benefits, eligibility issues, or other specific reasons as needed.
5. Complete the pharmacy information section. Fill in the pharmacy name, NABP number, address, and phone number, along with the pharmacist's signature and the date.
6. Document the prescription information. Include necessary details such as the date filled, Rx number, whether it is a new or refill prescription, medication name, strength, dosage form, quantity, and national drug code if applicable.
7. Sign the certification statement at the bottom of the form. Confirm that all information provided is correct and that fraudulent claims may lead to penalties. Provide the date of signature.
8. After verifying that all sections are complete, save your changes. You can then download, print, or share the form as needed for submission.

Take action now and complete your Po Box 968022 Schaumburg Form online for efficient processing.