Prescription Drug COB Claim Form
1. Patient Information
Full Name
Date of Birth
Member ID Number
Phone Number
Address
2. Coordination of Benefits Information
Is patient covered by another health plan?
Yes
No
If yes, name of other insurance
Policyholder Name
Policy Number
Effective Date
Relationship to Patient
3. Prescription Drug Information
Drug Name
Strength
Quantity
Date Filled
Pharmacy Name
Pharmacy Phone
4. Payment Information
Total Drug Cost
Amount Paid by Other Plan
Amount Paid by Member
Member Signature
Date