Universal claim form 2026

1. Click ‘Get Form’ to open the universal claim form in the editor.
2. Begin by filling out the Pharmacy Information section. Enter the pharmacy name, pharmacist's name, address, NABP number, and phone number accurately.
3. Next, move to the Cardholder Information section. Input the cardholder's name, phone number, address, city, state, zip code, birthdate, SSN/Subscriber ID, employer details, and group plan information.
4. Proceed to Patient Information. Fill in the patient's name, phone number, address details including city and state, birthdate, sex, and their relationship to the cardholder.
5. In the Prescription Information section, provide details such as medication name, prescription number, price, days' supply, date filled, dosage form and strength. Include active ingredient and quantity dispensed as well.
6. Finally, ensure all fields are completed accurately before submitting your form for processing.

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