Form C-14352 - Blue Shield Of California Prescription Drug Benefit - Direct Reimbursement Claim
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1
2Blue Shield of California Prescription Drug Benefit*
Direct Reimbursement Claim
*Applies to outpatient prescription drug benefits available through plans underwritten by Blue Shield of California and Blue Shield of California Life & Health Insurance Company.
PART ONE: To Be Filled Out By You
The undersigned certifies that the medication(s) described
heron was received by the undersigned for the party(s) named
below who is/are eligible for drug benefits, and that such
medication(s) is/are not for an on the job injury or covered under
SUBSCRIBER IDENTIFICATION NUMBER
PATIENT’S NAME
another benefit plan. The undersigned authorizes release of all
information to the plan administrator, underwriter, sponsor,
/
/
0 1 9 1 0 0 0 0
policy holder, employer and their agents for use in connection
with the benefit plan programs. Information may also be used
PATIENT’S DATE OF BIRTH (MM/DD/YY)
for other reporting and analysis purposes without identification
CUSTOMER NUMBER
of the undersigned or the undersigned’s family members. The
o MALE
o FEMALE
undersigned further authorizes use of such person’s subscriber
SEX:
identification number for identification purposes and further
recognizes that reimbursement will be paid directly to the
RELATIONSHIP:
SUBSCRIBER NAME
participant and assignment of these benefits to a pharmacy or
o SUBSCRIBER o SPOUSE
o CHILD
otherwise is void.
o OTHER:
MAIL ADDRESS – STREET
EXPLAIN RELATIONSHIP
X
(
)
SIGNATURE OF PATIENT, GUARDIAN OR LEGAL
REPRESENTATIVE
CITY
STATE
ZIP
DAYTIME TELEPHONE
PART TWO: Pharmacy Information - To Be Filled Out By You or Your Pharmacist
PHARMACY NAME
ADDRESS – STREET
PHARMACY NABP NUMBER
(
)
CITY
STATE
ZIP
PHARMACY TELEPHONE
Rx 1
Rx 2
TAPE PHARMACY RECEIPT
TAPE PHARMACY RECEIPT
Rx 3
Rx 4
TAPE PHARMACY RECEIPT
TAPE PHARMACY RECEIPT
For Compounds: Pharmacist to identify the specific
FOR COMPOUNDS
prescription by date of service and Rx number. Please list name,
NDC# and metric quantities of each ingredient in box on left.
X
Signature of Pharmacist for Compounds
C-14352 (10/03)
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