Follow the steps to complete the Gateway Health Plan NS 687B form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Part 1, enter the member ID from your Gateway Health Medicare AssuredSM ID card in the designated field.
3. Fill in the member name, address, and telephone number accurately.
4. Input the member's date of birth using the format Month, Day, Year.
5. Certify the information by signing the form, indicating that the provided information is accurate.
6. In Part 2, enter the pharmacy's name, address, and telephone number where the prescription was obtained.
7. For RX1, fill out the date of service, prescription number, NDC, the amount paid, quantity, days supply, and prescriber name. Repeat this for RX2, RX3, and RX4 accordingly.
8. Ensure you only use pharmacy receipts that include the required information, avoiding cash register receipts.
9. Once completed, review the form for accuracy, then save changes, download, or print the document for submission.
10. Mail the completed form to Gateway Health Medicare AssuredSM, Attention: Pharmacy Department, P.O. Box 22158, Pittsburgh, PA 15221.

Get started by completing the Gateway Health Plan NS 687B online now.