Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-13073 (10/08)

STATE OF WISCONSIN HFS 106.03(1), Wis. Admin. Code

COMPOUND DRUG CLAIM
Instructions: Type or print clearly. Before completing this form, read the Compound Drug Claim Completion Instructions, F-13073A. Return the completed form to: ForwardHealth, Claims and Adjustments, 6406 Bridge Road, Madison, WI 53784-0002. SECTION I -- PROVIDER INFORMATION
1. Name -- Provider 3. Address -- Provider (Street, City, State, ZIP+4 Code) 2. National Provider Identifier

SECTION II -- MEMBER INFORMATION
4. Member Identification Number 5. Name -- Member (Last, First, Middle Initial) 6. Date of Birth -- Member 7. Sex -- Member

SECTION III -- CLAIM INFORMATION
8. Prescriber Number 9. Date Prescribed 10. Date Filled 11. Refill 12. Days' Supply 13. Quantity Dispensed

14. Prescription Number

15. Pt Loc

16. Diagnosis Code

17. Level of Effort

SECTION IV -- COMPOUND INGREDIENTS

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC

Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity 19. Charge

Ingredient Cost

$
Ingredient Cost

14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC Ingredient NDC

Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity Ingredient Quantity

Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
Ingredient Cost

$
21. Patient Paid Amount 22. Net Billed

$
20. Other Coverage Amount

18. Other Coverage Code

$

$

$

$

23. Certification I certify that the services and items for which reimbursement is claimed on this claim form were provided to the previously named member pursuant to the prescription of a licensed physician, podiatrist, or dentist. Charges on this claim form do not exceed my (our) usual and customary charge for the same services or items when provided to persons not entitled to receive benefits under ForwardHealth. I understand that any payment made in satisfaction of this claim will be derived from federal and state funds and that any false claims, statements or documents, or concealment of a material fact may be subject to prosecution under applicable federal or state law. 24. SIGNATURE -- Pharmacist or Dispensing Physician 25. Date Signed

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