Get 14423-standard-0814 Prescription Reimbursement Claim Form ...

This guide provides step-by-step instructions on how to effectively fill out the 14423-STANDARD-0814 Prescription Reimbursement Claim Form online. By following these instructions, you can ensure accurate submission and processing of your prescription reimbursement claims.

Follow the steps to complete the form with ease.

1. Click 'Get Form' button to obtain the form and open it in your preferred editor.
2. Complete the card holder/patient information section. This includes entering the identification number, group number or name, name (last, first, MI), address, city, state, zip, and country. Ensure this section is fully completed for proper reimbursement.
3. Fill out the patient information section for each individual covered by the claim. Use a separate claim form for each person. Include their name, date of birth, relationship to the primary member (spouse, child, etc.), gender, and phone number.
4. Provide additional insurance information. Answer whether any medicines are related to an on-the-job injury and if the medicine is covered by another group insurance. If so, include the insurance company name and ID number.
5. Sign the form. A signature is required to confirm that you (or the eligible dependent) have received the medicine described and that all information is accurate.
6. Gather and attach all original pharmacy receipts. Ensure they include key information like the patient name, prescription number, NDC number, date of fill, quantity, total charge, days supply, and pharmacy details.
7. Include the prescribing physician's details, including their NPI number and contact information.
8. After filling out all necessary sections, review the form for completeness and accuracy. Save your changes, then download or print the form for submission.

Complete your prescription reimbursement claim form online today for efficient processing.