Get united american part d coordination of benefits form

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Other Coverage Section: (complete the information below if the patient has other prescription drug coverage programs) Other Insurance Company Name Other Policy Number Date of Service Drug Name Rx Number Other Policy Holder Name Charge Amount Patient Paid Amount Other Payor Paid PHARMACY INFORMATION (For Compound and Vaccine Prescriptions ONLY) List the VALID 11-digit NDC number for EACH ingredient used for the...
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united american part d coordination of benefits
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