M R O F T N E M E S R U B M I E R Y A P - F L E S R E B M E M M A R G O R P T I F E N E B N O I T P I R C S E R P CARDHOLDER - PATIENT INFORMATION ) d r a C . D . I m o r f ( R E B M U N P U O R G E M A N P U O R G E M A N R E Y O L P M E ) d r a C . D . I m o r f ( . O N R E B M E M ) d r a C . D . I m o r f ( . O N N O I T A C I F I T N E D I R E D L O H D R A C ) . I . M , e m a N t s r i F , e m a N t s a L ( E M A N R E D L O H D R A C H T R I B F O E T A D O T T N E I T A P F O P I H S N O I T A L E R X E S S ' T N E I T A P ) . I . M , e m a N t s r i F , e m a N t s a L ( E M A N T N E I T A P MALE CARDHOLDER: SELF SPOUSE MO DAY YEAR FEMALE CHILD OTHER MAILING ADDRESS OF CA E D O C P I Z E T A T S Y T I C ) t e e r t S d n a r e b m u N ( R E D L O H D R I CERTIFY THAT THE PATIENT FOR WHOM THIS CLAIM IS MADE IS A COVERED PERSON IN THIS BENEFIT PROGRAM AND THAT THESE PRESCRIPTIONS ARE FOR THE SOLE USE OF THE NAMED PATIENT. I ALSO CERTIFY THAT THE CLAIM(S) BEING SUBMITTED FOR PAYMENT ARE NOT ELIGIBLE FOR PAYMENT UNDER A NO-FAULT AUTOMOBILE OR WORKER'S COMPENSATION PROGRAM. (Cardholder/Authorized Representative Signature): X___________________________________________________ Telephone No: ( _____ ) ______________ PRESCRIPTION INFORMATION M R O F E G A S O D / H T G N E R T S / G U R D F O E M A N L L I F E R W E N D E L L I F E T A D R E B M U N X R E C I F F O R O F M I A L C NUMBER USE ONLY RX RX (If generic include manufacturer, if compounded Rx complete reverse side) 1 E C I R P N O I T P I R C S E R P R O N A I C I S Y H P G N I B I R C S E R P F O E M A N S Y A D . Y T Q C I R T E M E D O C G U R D L A N O I T A N MANUFACTURER PRODUCT NO. PKG. DISPENSED SUPPLY IDENTIFICATION NUMBER (i.e. DEA No./NPI) (Including all discounts) $ M R O F E G A S O D / H T G N E R T S / G U R D F O E M A N L L I F E R W E N D E L L I F E T A D R E B M U N X R E C I F F O R O F M I A L C NUMBER USE ONLY RX RX (If generic include manufacturer, if compounded Rx complete reverse side) 2 E C I R P N O I T P I R C S E R P R O N A I C I S Y H P G N I B I R C S E R P F O E M A N S Y A D . Y T Q C I R T E M E D O C G U R D L A N O I T A N MANUFACTURER PRODUCT NO. PKG. DISPENSED SUPPLY IDENTIFICATION NUMBER (i.e. DEA No./NPI) (Including all discounts) $ M R O F E G A S O D / H T G N E R T S / G U R D F O E M A N L L I F E R W E N D E L L I F E T A D R E B M U N X R E C I F F O R O F M I A L C NUMBER USE ONLY RX RX (If generic include manufacturer, if compounded Rx complete reverse side) 3 E C I R P N O I T P I R C S E R P R O N A I C I S Y H P G N I B I R C S E R P F O E M A N S Y A D . Y T Q C I R T E M E D O C G U R D L A N O I T A N MANUFACTURER PRODUCT NO. PKG. DISPENSED SUPPLY IDENTIFICATION NUMBER (i.e. DEA No./NPI) (Including all discounts) $ M R O F E G A S O D / H T G N E R T S / G U R D F O E M A N L L I F E R W E N D E L L I F E T A D R E B M U N X R E C I F F O R O F M I A L C NUMBER USE ONLY RX RX (If generic include manufacturer, if compounded Rx complete reverse side) 4 E C I R P N O I T P I R C S E R P R O N A I C I S Y H P G N I B I R C S E R P F O E M A N S Y A D . Y T Q C I R T E M E D O C G U R D L A N O I T A N MANUFACTURER PRODUCT NO. PKG. DISPENSED SUPPLY IDENTIFICATION NUMBER (i.e. DEA No./NPI) (Including all discounts) $ M R O F E G A S O D / H T G N E R T S / G U R D F O E M A N L L I F E R W E N D E L L I F E T A D R E B M U N X R E C I F F O R O F M I A L C NUMBER USE ONLY RX RX (If generic include manufacturer, if compounded Rx complete reverse side) 5 E C I R P N O I T P I R C S E R P R O N A I C I S Y H P G N I B I R C S E R P F O E M A N S Y A D . Y T Q C I R T E M E D O C G U R D L A N O I T A N MANUFACTURER PRODUCT NO. PKG. DISPENSED SUPPLY IDENTIFICATION NUMBER (i.e. DEA No./NPI) (Including all discounts) $ COMPOUNDED PRESCRIPTION CLAIM S E I T I T N A U Q / S T N E I D E R G N I D E D N U O P M O C L L I F E R W E N D E L L I F E T A D R E B M U N X R E C I F F O R O F M I A L C NUMBER USE ONLY RX RX 6 E C I R P N O I T P I R C S E R P R O N A I C I S Y H P G N I B I R C S E R P F O E M A N S Y A D . Y T Q C I R T E M E D O C G U R D L A N O I T A N MANUFACTURER PRODUCT NO. PKG. DISPENSED SUPPLY IDENTIFICATION NUMBER (i.e. DEA No./NPI) (Including all discounts) $ PHARMACY INFORMATION E H T R O F S I N W O H S E G R A H C E H T T A H T Y F I T R E C I Y C A M R A H P . P . B . A . N Y C A M R A H P F O R E B M U N E N O H P E L E T & S S E R D D A , E M A N DRUG(S) DISPENSED IDENTIFICATION NUMBER TO THIS RECIPIENT. (Signature and License No. of Pharmacist requested) X________________________________________ Form ROI00051 Rev. 3-1-03 PLEASE READ INSTRUCTIONS ON REVERSE SIDE