Summary: Complete information below if not found on receipt #2
National Drug Code
Drug Name___________________________Drug Strength ___________
Date of Service Rx#
Quantity Days Supply Amt. Paid
Prescription Information Receipt #1
The receipt(s) must contain the following information:
1. Rx #
2. Date prescription filled
4. Days Supply
5. National Drug Code (NDC)
6. Name of drug and strength
7. DAW code (if applicable)
8. Amount paid
Tape Prescription Receipt #1 Here No Staples
DRUG CLAIM FORM
1. Please type or print clearly. All information in each section must be provided.
2. All forms must be accompanied by an original prescription receipts.
3. A separate form must be completed for each patient.