TrueScripts - Claim Reimbursement

Prescription Drug Claim Reimbursement Form

Each Pharmacy Receipt Must Show:

Patient Name
Pharmacy Name and Address or NABP Number
Metric Quantity/Days Supply
Purchase Date

Reimbursement claim must be filed within 1 year

Prescription Number
Name/Strength and NDC Number
Dispense as written(DAW), if applicable
Total Charge

The submission of this claim form, for you or any of your dependents, authorizes the release of all information to applicable health care providers and all others involved in filling the prescription or processing the claims submitted.

Please complete sections 1 through 4.
Include receipts before mailing.

Please use a separate claim form for each covered member of the family.

1. Subscriber Information

Primary Patient ID

Plan/Group ID

Plan Sponsor/Employer

First Name

Last Name

Address Line 1

Address Line 2

City

State / Province

Postal / Zip Code

Daytime Phone Number Example: 555-555-0100

Extension

2. Patient Information

First Name

Last Name

Email TrueScripts respects your privacy and will manage all Personal Health information pursuant to 45 C.F.R & 164.504(e)(2)(1) and in accordance with the approved technologies and methodologies set out by HHS in its guidance (74 Fed Reg. 42740, 42742)

Date of Birth

Gender

Number of Receipts

Patient's Relationship to Card Holder

Was this prescription obtained while traveling outside the United States?

Coordination of Benefits

Is the medicine covered under any other group insurance? If yes, is other coverage:

Name of Insurance Company

Insurance Company ID

3. Reason for Claim or Special Notes

Reason For Claim

4. Attach Pharmacy Receipt

If unable to attach files electronically, please call the TrueScripts Clinical Services Team at 844.257.1955.

Attach File