Form C2001 - Coordination Of Benefits Form printable pdf download

Coordination of Benefits Form

See the back for instructions. Complete all information.

An incomplete form may delay your reimbursement.

Member/Subscriber Information See your prescription drug ID card.

Claim Receipts

Tape receipts or itemized bills on the back.

Group No.

See back for details.

Check the appropriate box if any

Member ID

receipts or bills are for a:

„ Compound prescription

Member Name (First, Last)

Make sure your pharmacist lists

ALL the VALID 11 digit NDC numbers

Street Address

and the ingredients and quantities

on the receipt or bill.

City

State

Zip

„ Medication purchased outside of

the United States

Patient Information

Please indicate:

Country

Patient Name (First, Last)

Currency used

Patient Date of Birth (Month/Day/Year)

„ Allergy medication

Sex

Relationship to Plan Member

„ Female

„

Coordination of Benefits

Self

Disabled Dependent

„ Male

„

Spouse

Dependent Parent

(Another Health Plan has paid a portion)

„

Eligible Child

Nonspouse Partner

Mark the appropriate box for your

„

Dependent Student „

Other

primary coverage method. See the back

for more information.

Pharmacy Information

„

Another Health Plan paid and you

are enclosing a statement that

Name of Pharmacy

outlines how much you paid and

how much the other carrier paid

Street Address

„

Card Program

„

Medco By Mail/mail-order

City

State

Zip

pharmacy

Telephone (include area code)

Any person who knowingly and with intent

to defraud, injure, or deceive any insurance

Is this an on-site nursing home pharmacy? „Yes

„No

company, submits a claim or application containing

I hereby certify that the charge(s) shown for the medication(s) prescribed is correct and agree to provide Medco or its

any materially false, deceptive, incomplete or

agents reasonable access to records related to medication dispensed to this patient in accordance with applicable law. I

misleading information pertaining to such claim

further recognize that reimbursement will be paid directly to the plan member and assignment of these benefits to a

may be committing a fraudulent insurance act

pharmacy or any other party is void.

which is a crime and may subject such person to

criminal or civil penalties, including fines and/or

imprisonment, or denial of benefits.*

Signature of Pharmacist or Representative

NABP Number Required

Please tape receipts on the back.

(Required)

Acknowledgment

I certify that the medication(s) described above was received for use by the patient listed above, and that I (or the patient, if not myself)

am eligible for prescription drug benefits. I also certify that the medication received was not for an on-the-job injury or covered under

another benefit plan. I recognize that reimbursement will be paid directly to me, and that assignment of these benefits to a pharmacy or

any other party is void.

Signature of Member

C2001 11-05

Form C2001 - Coordination Of Benefits Form

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