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Prescription Drug Claim Form - ProCare Rx 2026
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- Click ‘Get Form’ to open the Prescription Drug Claim Form - ProCare Rx in our editor.
- Begin by filling out the 'Insured/Patient Information' section. Enter the cardholder's last name, first name, middle initial, and address. Ensure you include the plan name and cardholder ID number.
- Provide your contact details including home and work phone numbers. Fill in the employer's address and group number if applicable.
- Indicate whether there is any additional group insurance that may cover this claim by checking 'YES' or 'NO'. If applicable, provide the insurance name and group number.
- In the 'Claim Information' section, list each pharmacy used for prescriptions. Include pharmacy ID, name, days supplied, NDC number, fill date, Rx number, prescriber’s name, and metric quantity for each prescription.
- Complete the 'Reason for Claim Submission or Special Notes' section as needed.
- Finally, sign and date the authorization section to certify that all information provided is accurate.
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