Get 14423-standard-0914 Prescription Reimbursement Claim Form ... - Newburghschools

Navigating the 14423-STANDARD-0914 Prescription Reimbursement Claim Form can be straightforward if you follow the appropriate steps. This guide will assist you in completing the form accurately to ensure a smooth reimbursement process.

Follow the steps to fill out the Prescription Reimbursement Claim Form successfully.

1. Press the ‘Get Form’ button to obtain the Prescription Reimbursement Claim Form and open it in your preferred editor.
2. Complete the card holder/patient information section thoroughly. This includes providing the full name (last name, first name, and middle initial), address, city, state, zip code, and country of the card holder. Additionally, fill out the patient information including the patient’s name, date of birth, relationship to the primary member, and contact number.
3. Address any other insurance information if applicable. Indicate whether any of the medicines are being taken for an on-the-job injury and if the medicine is covered under any other group insurance. For any other coverage, specify if it is primary or secondary and provide the name of the insurance company along with the ID number.
4. Ensure to sign the form in the designated area, certifying that all information provided is accurate and true. Include the date of signing to validate the claim.
5. Gather all original pharmacy receipts as the next step for submission. Ensure that your pharmacy receipts include essential details such as the patient name, prescription number, medicine NDC number, date of fill, metric quantity, total charge, days supply, and the pharmacy name and address or NABP number.
6. After completing the form and assembling the receipts, follow the mailing instructions. Prepare your documents for mailing to the specified address: CVS/caremark, P.O. Box 52136, Phoenix, Arizona 85072-2136.
7. Once everything is filled out and prepared for submission, you can save changes, download the form, print it, or share it as needed.

Get started on your prescription reimbursement claim today by completing the form online.