2017-0620W Name Street Address City State ZIP Code Pharmacy National Provider Number (NPI) Telephone Number ( ) Part 3: Receipt Information 1. Include original pharmacy receipt(s) or pharmacy printout(s); Cash Register Receipt(s) without pharmacy detail will not be accepted. Tape original pharmacy receipt(s) to bottom of this page. Please DO NOT staple. 2. Receipt(s) must contain the information outlined under Part 3. If your receipt(s) are missing any of this information, have your pharmacist fill in the missing information under Part 3. 3. Please provide the explanation of benefits (EOB) or denial letter from the primary insurance carrier if you have primary coverage with another insurance carrier. 4. An incomplete form may be denied, delayed or returned. 5. Receipts will not be returned, remember to keep a copy of the completed claim form and receipt(s) for your records. Rx Written Date Date Rx Filled Medication Name Rx Number Diagnosis Code and Description National Drug Code Quantity Day Supply Prescribing Physician First/Last Name Prescribing Physician NPI Original Cost of Rx Amount Primary Insurance Paid on Rx Member Paid Amount Mail this form along with receipts to: Navitus Health Solutions, LLC P.O. Box 999 Appleton, WI 54912-0999 OR Fax this form along with receipt(s) to: (920)735-5315 / Toll Free (855)668-8550