Dhs 204 claim fill: Fill out & sign online

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Click ‘Get Form’ to open the DHS 204 form in our editor.
Begin by entering the Recipient's Name and Identification Number in the designated fields. Ensure accuracy as this information is crucial for processing.
Fill in the Date of Birth and Pharmacy details, including NPI and Address. This section helps identify the pharmacy involved in the prescription claim.
Complete the Prescriber’s information, including NPI and DEA number if applicable. This is essential for verifying the legitimacy of the prescription.
Indicate any other drug or liability coverage by checking 'Yes' or 'No' and provide details if applicable. This ensures all potential coverage options are considered.
For each prescribed medication, enter details such as RX Number, Drug Name/Strength, Metric Quantity, Days Supply, and DAW Code. Repeat this for multiple prescriptions as needed.
Finally, review all entered information for accuracy before signing at the bottom of the form to certify that all provided information is true and complete.

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