Get Pfizer Encompass Claim Form

This guide provides a comprehensive overview for users on how to complete the Pfizer Encompass Claim Form online. By following these steps, you can efficiently fill out the required information and submit your claim for assistance with your medication.

Follow the steps to fill out the Pfizer Encompass Claim Form online

1. Click the ‘Get Form’ button to download the claim form and open it in the online editor.
2. Begin by entering the administering provider's information. Fill in the practice name, as well as the first and last name of the provider.
3. Next, input the patient's details. Fill out the first name, last name, and middle initial if applicable. Also, provide the zip code, date of birth, date of service, group number, and member ID number.
4. Indicate the patient's gender by selecting 'Male' or 'Female.'
5. Update the insurance details if necessary. Include the primary insurance name as well as their BIN and group numbers for both pharmacy and medical benefits.
6. Finally, enter the patient’s out-of-pocket amount for INFLECTRA and verify all fields marked with an asterisk (*) are completed.
7. Once all information is filled in, save any changes made to the form. Download or print the completed form, and share or fax it as instructed.

Complete your Pfizer Encompass Claim Form online today to get started with your claim!