Get Universal Claim Form - Park Compounding

Filling out the Universal Claim Form for a compounded medication is essential for obtaining reimbursement from your insurer. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the Universal Claim Form online.

1. Click ‘Get Form’ button to access the Universal Claim Form and open it in your preferred editor.
2. In the Patient Information section, enter the date, pharmacist's license number, NABP number, and the patient's personal details such as name, telephone, address, date of birth, sex, and social security or subscriber I.D. number.
3. Fill in the Patient's Relationship to Cardholder along with the employer information including the employer name, employer I.D., group number, and plan number.
4. In the Patient Authorization section, the patient must sign and date to authorize the release of information and the execution of any assignment of benefits documents.
5. Proceed to the Prescription Information section. Here, note the medication name, prescription number, date filled, price, days supply, dosage form, strength, active ingredients, and the quantity dispensed.
6. Have the prescriber’s name and DEA number completed. The pharmacist must then certify the information by signing the Pharmacist Authorization section.
7. Finally, review all entries for accuracy. Once confirmed, you can save changes, download, print, or share the form as necessary.

Complete your Universal Claim Form - Park Compounding online for efficient processing of your compounded medication claims.