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02. Sign it in a few clicks
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03. Share your form with others
Send bcbsnc claim form via email, link, or fax. You can also download it, export it or print it out.
How to use or fill out medication claim with our platform
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Click ‘Get Form’ to open the medication claim in the editor.
Begin by filling out the Patient Information section. Enter the patient's name, telephone number, address, birthdate, and social security/subscriber ID number.
Next, provide details about the cardholder including their name, relationship to the patient, and employer information.
In the Patient Authorization section, ensure that the patient signs and dates to authorize release of information related to their treatment.
Proceed to fill out the Prescription Information. Include medication name, prescription number, date filled, dosage form, strength, active ingredients, and quantity dispensed.
Finally, have the pharmacist sign in the Pharmacist Authorization section certifying that the compounded medication was specifically ordered for the patient.
Start using our platform today for free to streamline your medication claim process!
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Please attach receipts to space provided on the back of form . If receipts are not included, please have pharmacist complete and sign the bottom of this form .Read more
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Patients who received an opioid prescription more likely to have a subsequent abuse-related claim* compared to non-exposed. (5.8% vs. 0.4%). AdjustedRead more
The provider understands that payment of this claim will be from Federal and / or State funds, and that any falsification, or concealment of a material fact,Read more
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