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Universal Claim Form for a Compounded Medication Recognized by the International Academy of Compounding Pharmacists Patient Information State Sex Zip Social Security/Subscriber I. D. No* Patient s Relationship to Cardholder City Birthdate Employer Employer I. D. Group No* Plan No* Patient Authorization I hereby authorize release of information to health care providers institutions and /or payers that may pertain to my illness and/or treatment received* I certify that the information I have reported with regard to my insurance coverage is correct and I have received the pharmacist care/services rendered* Patient Signature Date to make payment directly to Pharmacy or its assigns. I understand that any amounts not paid by insurer because of deductible clauses lack of coverage or refusal to accept assignment of benefits shall be my responsibility. Prescription Information Medication Name Prescription Number Price Days Supply Date Filled Dosage Form Strength Active Ingredients Quantity Dispensed Prescriber s Name DEA Pharmacist Authorization I hereby certify that the above compounded medication was ordered by the stated prescriber specifically for the stated patient. This medication is not commercially available in this formulation or dosage form* The compounding was done using the highest possible standards pure chemicals or drugs and contemporary technology. Because this prescription medication is compounded and not manufactured an NDC number is not required for reimburesement. Pharmacist Signature If you have difficulty in submitting this form or receiving payment from your insurance company please contact us your employee benefits manager or the State Insurance Commissioner at Form Number USC0001 International Academy of Compounding Pharmacists Pharmacist Telephone Address Name NABP Pharmacist s License Pharmacist s Name Cardholder Information PHARMACY INFORMATION. D. No* Patient s Relationship to Cardholder City Birthdate Employer Employer I. D. Group No* Plan No* Patient Authorization I hereby authorize release of information to health care providers institutions and /or payers that may pertain to my illness and/or treatment received* I certify that the information I have reported with regard to my insurance coverage is correct and I have received the pharmacist care/services rendered* Patient Signature Date to make payment directly to Pharmacy or its assigns. I understand that any amounts not paid by insurer because of deductible clauses lack of coverage or refusal to accept assignment of benefits shall be my responsibility. I understand that any amounts not paid by insurer because of deductible clauses lack of coverage or refusal to accept assignment of benefits shall be my responsibility. Prescription Information Medication Name Prescription Number Price Days Supply Date Filled Dosage Form Strength Active Ingredients Quantity Dispensed Prescriber s Name DEA Pharmacist Authorization I hereby certify that the above compounded medication was ordered by the stated prescriber specifically for the stated patient. .