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Get Apwu Health Plan Policy Number Form

PATIENT S BIRTH DATE IF ADDRESS INCORRECT PLEASE CORRECT ABOVE / 5. PATIENT S SEX CIRCLE MALE 6. PATIENT S APWU GROUP NUMBER AS INDICATED ON YOUR FEMALE 7. DOES PATIENT HAVE MEDICARE IF YES PLEASE INDICATE EFFECTIVE DATE AND ATTACH EOMB FROM MEDICARE CARRIER. u PART A EFFECTIVE DATE 8. IS PATIENT COVERED UNDER ANY OTHER HEALTH INSURANCE YES u NO u IF YES PLEASE INDICATE NAME OF POLICY HOLDER. PLAN NAME ADDRESS POLICY NO. CARRIER USE ONLY APWU HEALTH PLAN P. O. BOX 1358 GLEN BURNIE MD 21060 PHONE 800-222-APWU PRESCRIPTION DRUG CLAIM FORM PATIENT AND INSURED SUBSCRIBER INFORMATION 1. INSURED S ID NUMBER 3. PATIENT CHECK PATIENT S NAME ONLY ONE PATIENT PER CLAIM FORM 2. INSURED S NAME ADDRESS 4. PATIENT S BIRTH DATE IF ADDRESS INCORRECT PLEASE CORRECT ABOVE / 5. PATIENT S SEX CIRCLE MALE 6. PATIENT S APWU GROUP NUMBER AS INDICATED ON YOUR FEMALE 7. DOES PATIENT HAVE MEDICARE IF YES PLEASE INDICATE EFFECTIVE DATE AND ATTACH EOMB FROM MEDICARE CARRIER* u PART A EFFECTIVE DATE 8. IS PATIENT COVERED UNDER ANY OTHER HEALTH INSURANCE YES u NO u IF YES PLEASE INDICATE NAME OF POLICY HOLDER* PLAN NAME ADDRESS POLICY NO. AND PHONE NO. IF NO PLEASE SIGN AND DATE* 9. WAS CONDITION RELATED TO A. PATIENT S EMPLOYMENT YES u NO u IF YES INDICATE FILE NO. B. AN AUTO/MOTORCYCLE ACCIDENT YES u NO u PLEASE CIRCLE ONE 8. IF YES PLEASE ATTACH PAYMENT STATEMENT FROM OTHER CARRIER* 10. PATIENT S OR AUTHORIZED PERSON S SIGNATURE AUTHORIZING THE RELEASE OF ALL MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM. SIGNED DATE CLAIMS FILING INSTRUCTIONS Please Print The member must complete and sign this form* You must attach supporting receipts. Cancelled checks and balance due statements are not acceptable. Please list purchases in date order. 1. Non-prescription items and over-the-counter drugs are not covered* 2. RX NDC National Drug Code and NABP Pharmacy Identi cation Numbers are required* 3. Claims must be submitted by December 31 of the year after the year you incur the expense. Failure to le within this limit will invalidate your claim* Date of Purchase Rx Number NDC Number 11 Digits Brand or Generic Name of Drug Days Supply Qty. Prescribing Physician Drug Charge I certify the Rx drugs listed were purchased for the patient named and DO NOT include drugs that can be purchased OVER THE COUNTER with or without a doctor s prescription* Supplier s Federal Tax ID Number WARNING Any intentional false statement on this claim or willful misrepresentation relative thereto is a violation of the law etc* 18 U*S*C. 1001. REV 5/02 Pharmacy NABP Number Pharmacist s Signature Pharmacy Name and Address I certify the above statement to be correct. CARRIER USE ONLY APWU HEALTH PLAN P. O. BOX 1358 GLEN BURNIE MD 21060 PHONE 800-222-APWU PRESCRIPTION DRUG CLAIM FORM PATIENT AND INSURED SUBSCRIBER INFORMATION 1. INSURED S ID NUMBER 3. PATIENT CHECK PATIENT S NAME ONLY ONE PATIENT PER CLAIM FORM 2. INSURED S NAME ADDRESS 4. INSURED S ID NUMBER 3. PATIENT CHECK PATIENT S NAME ONLY ONE PATIENT PER CLAIM FORM 2. INSURED S NAME ADDRESS 4. PATIENT S BIRTH DATE IF ADDRESS INCORRECT PLEASE CORRECT ABOVE / 5. PATIENT S SEX CIRCLE MALE 6. PATIENT S APWU GROUP NUMBER AS INDICATED ON YOUR FEMALE 7.

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