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Get Prescription Drug Claim Form A

Y State ZIP Why was the insurance or drug card not used for this purchase? Explain below. Patient's Date of Birth Patient's Gender M F Patient's Relationship to Cardholder Self Spouse Child Other Is the patient eligible for Medicare, Part D (prescription drug) coverage? No Yes B. Other Insurance Coverage Is the patient eligible for primary prescription drug coverage from another provider? No Yes Insured's Name (Last, First, MI) If Yes, please use other insurance card to complete the f.

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