Get Express Scripts Com Easyeob

Filling out the Express Scripts Com Easyeob form online can seem daunting, but with the right guidance, you can complete it efficiently. This guide provides step-by-step instructions to help you understand each section of the form and ensure all necessary information is included.

Follow the steps to fill out the form accurately and effectively.

1. Click the ‘Get Form’ button to access the Express Scripts Com Easyeob form and open it for editing.
2. Provide patient information by entering the patient's name, date of birth, gender, and ID number. Be sure to check the box if this is a new address.
3. Fill in the patient’s mailing address and daytime telephone number. Ensure accuracy for prompt communication.
4. Indicate the health plan name and group number as found on your prescription drug or health insurance card.
5. Specify whether Medicare Part D is the patient's primary insurance by selecting 'yes' or 'no.'
6. If applicable, indicate if the patient has primary coverage under another plan. If you select 'yes,' attach an explanation of benefits from the primary carrier.
7. For the prescription information, indicate the number of receipts attached. All required details must be present, including pharmacy name, patient’s name, drug name, strength, NDC, date filled, and price.
8. Attach the prescription receipts or labels securely to a separate piece of paper. Please ensure they are not stapled.
9. If the claim is for diabetic supplies, specify this by selecting 'yes' and ensure the receipts include necessary details as outlined.
10. Sign and date the form, certifying that all information is accurate, and authorize the release of your information to Express Scripts, Inc.
11. Once the form is completed, save your changes, and then download, print, or share the completed document as needed.

Complete your Express Scripts Com Easyeob form online today for efficient processing.