Fillable Online Pharmacy Benefit Exception Request Form 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'Nature' section, selecting either 'Bodily Injury' or 'Other' as applicable.
3. Provide details about the incident, including the time, date, event name, and location. Ensure accuracy for effective processing.
4. In the 'Happened To' section, enter the individual's name, social security number, date of birth, sex, and contact information.
5. Describe the injury condition and any on-site care received. Specify if an ambulance was involved and where the individual was taken.
6. Complete the insurance information section by indicating whether other accident medical coverage exists and providing relevant details.
7. Finally, ensure all signatures are obtained from authorized representatives before submitting the form via fax or mail.

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