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MedImpact Prescription Drug Claim Form

MedImpact Prescription Drug Claim Form

 

INSTRUCTIONS: MEDIMPACT PRESCRIPTION DRUG CLAIM FORM
 
Alabama public employees enrolled in the PEEHIP health insurance program use the prescription drug claim form discussed in this article to obtain coverage for their prescription drug purchases. This document can be obtained from the website of the Retirement Systems of Alabama.
 
MedImpact Prescription Drug Claim Form Step 1: The first section requires information about the primary member or cardholder. In the first two boxes, give their ID number and full name.
 
MedImpact Prescription Drug Claim Form Step 2: In the next three lines, provide the name of the health plan or insurance, the member's daytime phone number, and the member's evening phone number.
 
MedImpact Prescription Drug Claim Form Step 3: In the next four boxes, provide the member's street address, city, state and zip code.
 
MedImpact Prescription Drug Claim Form Step 4: The next section should only be filled out if the patient is not the same as the primary member or cardholder. In the first two boxes, enter the patient's name and date of birth.
 
MedImpact Prescription Drug Claim Form Step 5: Indicate the patient's relationship to the primary member or cardholder with a checkmark.
 
MedImpact Prescription Drug Claim Form Step 6: Enter the patient's street address, city, state and zip code in the next four boxes.
 
MedImpact Prescription Drug Claim Form Step 7: If you have any other coverage, enter its name.
 
MedImpact Prescription Drug Claim Form Step 8: If you have worker's compensation, stop filling out this form and submit your claims to your employer.
 
MedImpact Prescription Drug Claim Form Step 9: The next section requires details about all prescriptions relevant to this claim. You may either complete this section yourself and submit it with supporting prescription labels and receipts or have your pharmacist complete this section. 
 
MedImpact Prescription Drug Claim Form Step 10: The claimant should sign the form where indicated at the top of the first page.
 
MedImpact Prescription Drug Claim Form Step 11: The final section concerns compound prescriptions and can only be completed by a pharmacist.
 
MedImpact Prescription Drug Claim Form Step 12: When submitting this form, it must be accompanied the original prescription label or receipt. Copies are not acceptable. Submit to the claim and prescription labels or receipts to the address at the top of the first page.
 

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