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Get Pharmacy Manual Claim Form - Goldcoasthealthplan

N of data if incomplete. A member pharmacy receipt is required on each transaction. Put your cursor on top of each shaded area and type in the information required. 3. You may submit via US Mail to Scriptcare LTD 6380 Folsom Dr. Beaumont Texas 77706, or fax to 409-833-7435. 4. Please allow up to 8 weeks for processing. Section 1 Cardholder Name: Patient Name: Patient DOB: / Member ID: Group ID: Gold Coast Health Plan / Section 2 Pharmacy Name: Pharmacy NABP: Pharmacy Address: Pharmacy Phone.

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