Get Schaumburg, Il 60196-8022

This guide provides clear and comprehensive instructions for completing the Schaumburg, IL 60196-8022 member reimbursement drug claim form online. By following these steps, you will ensure that your claim is processed efficiently and correctly.

Follow the steps to effectively complete the form online.

1. Press the ‘Get Form’ button to access the member reimbursement drug claim form and open it in your preferred online editor.
2. Begin by filling out the cardholder information section. Provide the cardholder’s ID number, employer/group name and number, as well as the cardholder’s name in the format (Last, First, Middle). Include their birthdate in the MM/DD/YYYY format, address, and telephone number.
3. Next, navigate to the patient information section. Here, include the patient name (First, Middle, Last) and select their gender. Indicate the patient’s relationship to the cardholder by checking the corresponding box (employee, spouse, or dependent) and provide the patient’s birthdate.
4. In the reason for request section, select the appropriate option regarding the claim, such as coordination of benefits, eligibility issues, or other. If necessary, provide additional details.
5. Complete the pharmacy information section by entering the pharmacy name, NABP number, address, and telephone number. Ensure the pharmacist's signature and the date are included.
6. Proceed to fill out the prescription information section. Attach the required prescription labels or pharmacy printout and fill in relevant details for each prescription, including the date filled, Rx number, medication name, strength, dosage form, day’s supply, quantity, national drug code, and physician’s name.
7. Once you have filled in all necessary sections and confirmed the accuracy of the information, certify your submission by signing and dating the form.
8. Finally, save your changes. You can download, print, or share the completed form for submission.

Take the next step in managing your healthcare expenses by completing the necessary documents online.