Get the free OTC Order Form AHCA 040110 PHC Form 11.1.doc

Over-the-Counter Pharmacy Order Form You can order up to $25 worth of over-the-counter (OTC) pharmacy items every month for your household. All available OTC items are listed on this form. There is

How to fill out otc order form ahca

Who needs otc order form ahca?

1. Medicare beneficiaries who are enrolled in a Medicare Advantage plan or a Medicare Prescription Drug plan (Part D).
2. Medicaid members who receive services through a Long-term Care Managed Care plan or a Managed Medical Assistance program.
3. Individuals who are eligible for both Medicare and Medicaid (also known as dual-eligible individuals).

How to fill out otc order form ahca:

1. Start by entering your personal information, including your name, address, phone number, and Medicare or Medicaid number.
2. Indicate the plan you are enrolled in by providing the name of the plan, your member ID, and the effective date of your coverage.
3. Select the items you want to order by checking the appropriate boxes or writing the item names and quantities in the provided spaces.
4. If there is a limit on the number of items you can order per quarter or per year, make sure to stay within that limit.
5. Calculate the total cost of the items you are ordering based on the prices listed on the form.
6. If there is a required copayment or coinsurance amount, indicate the payment method you prefer (such as deducting it from your future Medicare or Medicaid benefits or paying by check).
7. Sign and date the form, and make a copy for your records before submitting it to the address listed on the form or through the designated submission method (such as fax or online).

Remember to review the form carefully and ensure that all the information you provide is accurate and complete. It is also important to familiarize yourself with any specific instructions or guidelines provided by your plan regarding the use of the otc order form.

For pdfFiller’s FAQs

What is otc order form ahca?

The OTC (Over-the-Counter) order form AHCA is a form used to order approved OTC medications and products through the AHCA (Agency for Health Care Administration) for Medicaid recipients.

Who is required to file otc order form ahca?

Medicaid providers who wish to order approved OTC medications and products for Medicaid recipients are required to file the OTC order form AHCA.

How to fill out otc order form ahca?

The OTC order form AHCA can be filled out by providing the necessary recipient and provider information, selecting the approved OTC medications and products, and submitting the form according to the instructions provided.

What is the purpose of otc order form ahca?

The purpose of the OTC order form AHCA is to facilitate the ordering and distribution of approved OTC medications and products for Medicaid recipients.

What information must be reported on otc order form ahca?

The OTC order form AHCA typically requires information such as recipient details, provider information, selected OTC medications and products, quantity needed, and any other relevant information.

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