Full Text
PRESCRIPTION DRUG CLAIM FORM 1. Please type or print clearly. All information in each section must be provided. Mail completed form Blue Cross Blue Shield Incomplete forms will be returned, causing a delay in payment. and receipts to: of Wyoming 2. Attach original receipts to this form. P O Box 2266 3. A separate form must be completed for each patient and for each pharmacy patronized. Cheyenne, WY 82003 4. The insured person must sign each claim form submitted. SUBSCRIBER INFORMATION: Carrier Name: Street Address: Contract City: State: Zip: Company: I certify that the information is correct and that the patient indicated below is eligible for benefits. I have received the medication described herein and authorize the release of all information contained on this claim form to Blue Cross Blue Shield of Wyoming. I agree that any benefits payable hereunder for prescription drugs are not assignable and that any assignment thereof shall be void. I further represent that there has been no assignment of benefits hereunder. Why were you unable to use your ID Card? SUBSCRIBER SIGNATURE: PATIENT INFORMATION: PHARMACY INFORMATION: Patient Name: Pharmacy Name: Date of Birth: Male Female Pharmacy Address: Patient’s Relationship to the Insured: City: State: Zip: Self Spouse Dependent Pharmacy NABP Number*: *You may need to call the pharmacy for this number PRESCRIPTION CLAIM INFORMATION: 1 – Prescription Number: Date Filled: Name of Medication: NDC Number*: *You may need to call the pharmacy for this number Prescription Cost: Quantity: Days Supply: 2 – Prescription Number: Date Filled: Name of Medication: NDC Number*: *You may need to call the pharmacy for this number Prescription Cost: Quantity: Days Supply: 10/13