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Pharmacy Contract Request Form Inquiry type (select one) New pharmacy contract Change of pharmacy address/phone/fax/email Change of pharmacy ownership (provide previous owner and NCPDP in comments

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What is pharmacy contract request form?

The pharmacy contract request form is a document that pharmacies use to request contracts with payers or insurance companies to provide services and receive reimbursement for medications and other pharmaceutical care.

Who is required to file pharmacy contract request form?

Pharmacies that wish to establish or modify their contractual agreements with insurance providers or pharmacies that want to join a network are required to file a pharmacy contract request form.

How to fill out pharmacy contract request form?

To fill out the pharmacy contract request form, pharmacies must provide essential information, including business name, address, tax ID number, contact information, and details about the services offered, as well as any required supporting documents.

What is the purpose of pharmacy contract request form?

The purpose of the pharmacy contract request form is to initiate the process of establishing a formal agreement between a pharmacy and a payer, ensuring that the pharmacy can bill for services and receive appropriate reimbursement.

What information must be reported on pharmacy contract request form?

The information that must be reported on a pharmacy contract request form typically includes the pharmacy's legal name, address, contact information, National Provider Identifier (NPI), license details, and any relevant documents supporting the request.

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