Follow the steps to complete the CVS Caremark 14423 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the card holder/patient information section. This area must be fully filled out to ensure proper reimbursement. Include the identification number from your prescription card and the group number or name. Provide your last name, first name, middle initial, and complete address, including city, state, and zip code.
3. Indicate the reason you are filing this form by selecting the appropriate option. If medications were purchased outside of the United States, provide the country name and the currency used.
4. If there is other insurance information, complete the coordination of benefits section. Include the last name, first name, date of birth, relationship to the primary member, and indicate whether the individual is male or female. Fill in the phone number and any other details related to the other insurer.
5. Provide pharmacy information, including the name, address, and city of the pharmacy. Indicate any reasons why insurance might not have been accepted. If applicable, confirm if any medication is for an on-the-job injury and if it is covered under another insurance.
6. Fill in the required prescribing physician information, including their NPI number, name, address, and phone number.
7. After completing all sections, ensure you attach the original pharmacy receipts, as these are necessary for processing your claim. Be sure that they contain all the required information listed.
8. Once all information is verified and filled out correctly, sign the form and date it. This certification is mandatory.
9. Mail the completed form, along with the required receipts, to CVS Caremark at the provided address.

Complete your CVS Caremark 14423 form online today to ensure efficient processing of your prescription reimbursement claims.