.Patient Name
(last name first name mi)
.Date of Delivery
.(MM - DD - YY)
We do not need the RX number, NDC number or Lot number or Brand Name
text entry area
If check boxes can't be used, enter product info and QTY.
Also use this box for Client Name & Number if needed.
.ARE YOU ACCEPTING ASSIGNMENT ? If this claim is for a Medicare Claim *
.YES NO * ( only non participating Medicare providers may check NO )