pharmacy bill format pdf
New York State Electronic Medicaid
This document is customized for Pharmacies and should be used by the provider as an instructional, as well as a reference tool.
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Prescription Reimbursement Claim Form
Please make sure the receipt or itemized printout includes the patients name, prescription number, date filled, dispensing pharmacy name and address, drug name
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PHARMACY INVOICE
PHARMACISTS SIGNATURE: Pharmacist must sign and date the invoice. Signature stamps are acceptable. 28. REMARKS: Explain any unusual charges such as compound
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