Get Allergenic Extract Claim Form - Pebtf - Pebtf

Completing the Allergenic Extract Claim Form online is a straightforward process that ensures you receive reimbursement for your allergenic extract treatment. This guide will walk you through each section of the form with clear and informative instructions.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Begin by entering your member or subscriber information. Refer to your prescription drug ID card for the group number and member ID. Enter your full name, street address, city, state, and zip code in the respective fields.
3. Complete the patient information section by specifying the patient’s gender, full name, date of birth (month/day/year), and relationship to the plan member by selecting the appropriate option.
4. In the certification statement, affirm that the information you provided is accurate and that the medication has been received. Sign and date this section.
5. In the pharmacist or physician section, provide the pharmacy or physician's information, including the date of purchase, name, address, and telephone number.
6. Document the number of treatments, number of vials, and days’ supply. Specify whether the vial contains a single antigen or multiantigen and include the charge per treatment.
7. Detail the total charge for the allergenic extract only and ensure the pharmacist or physician certifies the charges on the form with their signature and date.
8. Attach the itemized bill from your physician or pharmacist to your claim form for verification.
9. Once all sections have been completed and verified for accuracy, submit the form to the designated address for CVS Caremark.

Take action today by completing the Allergenic Extract Claim Form online to ensure timely reimbursement.