Prescription Insurance Claim
Prescription Insurance Claim
Claimant Information
-
Name: [Your Name]
-
Email: [Your Email]
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Insurance ID: INS123456789
Prescription Details
|
Medication Name |
Prescribing Doctor |
Date Prescribed |
Quantity |
Dosage |
|---|---|---|---|---|
|
Lisinopril |
Dr. Janeth Hill |
2050-09-15 |
30 tablets |
10mg |
Costs Incurred
|
Medication Name |
Pharmacy |
Cost |
Date of Purchase |
|---|---|---|---|
|
Lisinopril |
HealthPlus Pharmacy |
$45.00 |
2050-09-16 |
Insurance Coverage
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Policy Name: Comprehensive Health Plan
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Coverage Percentage: 80%
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Deductible Amount: $100.00
Amount To Be Reimbursed
Total Cost: $45.00
Amount Covered by Insurance: $36.00 (80% of $45.00)
Amount To Be Reimbursed: $36.00, after deductible fulfillment.
Supporting Documents
Attached are the original prescription from Dr. Janeth Hill and the receipt from HealthPlus Pharmacy dated September 16, 2050.
Claimant's Declaration
I, [Your Name], hereby affirm that the information provided in this insurance claim is accurate and complete to the best of my knowledge. I acknowledge that any misrepresentation or false information may result in the denial of my claim or other legal consequences.
[YOUR NAME]
[DATE SIGNED]
