Get Universal Claim Form

Filling out the Universal Claim Form online is a straightforward process that allows you to submit your medication claims efficiently. This guide provides clear, step-by-step instructions to help you complete the form accurately and successfully.

Follow the steps to complete the Universal Claim Form online.

1. Click ‘Get Form’ button to obtain the Universal Claim Form and access it in your preferred online editor.
2. In the Cardholder Information section, enter the cardholder's name, telephone number, and address, including city, state, and zip code. Make sure to accurately list the birth date and the social security or ID number.
3. Indicate the patient's relationship to the cardholder by selecting the appropriate option and providing the patient’s personal details: name, telephone number, address, and their birth date, sex, and social security or ID number.
4. Fill out the employer and employer ID fields, along with the group number and plan number, to provide the necessary insurance information.
5. In the Patient Authorization section, read the statement and provide the patient’s signature, along with the date, confirming the release of information and correctness of insurance details.
6. Enter the prescription information, including the medication name, prescription number, price, days supply, date filled, dosage form, strength, active ingredients, and quantity dispensed.
7. Provide the prescriber’s name and DEA number as required for the medication being claimed.
8. In the Pharmacist Authorization section, the pharmacist must certify the medication's specifications by providing their signature and date, ensuring compliance with compounding standards.
9. Once you have completed all the sections, review the form for accuracy. You can then save your changes, download, print, or share the form as required.

Start filling out your Universal Claim Form online today to ensure a smooth claims process.