The file's text, extracted by GovTribe without its formatting.
VAMC INITIAL FILL Rx CERTIFICATE
| Instructions to Pharmacy |
| Instructions to Veteran |
| Submit claims to |
| Certificate must be surrendered with prescription to the pharmacy. |
| BIN #: Person Code: |
| Provide the pharmacy with your SSN (below). |
| Processor Control Number: |
| This certificate is not transferable and the benefit can only be claimed by the person named below. Certificate is a ONE-TIME use ONLY. |
Use 9-digit SSN as ID number
| Group #: |
| This plan only covers VA approved formulary prescriptions written by an approved provider at the VA clinic. |
Prescriber must be an approved VA Provider
| Maximum Day Supply is: 10 (10 for antibiotics) |
| No Co-pays are to be charged to veterans for approved medications. |
| If you have any questions, please call our Customer Service Desk Toll Free |
| Date: |
| __________________________ |
| Group # |
| Hours: Mon-Fri |
| CBOC Name: |
| Please be sure to tell Customer Service you are calling about the VA program. |
| Provider Name: |
Certificate is only valid when accompanied with a script written on official VA prescription form.
Veteran Name:
| NO REFILLS ARE ALLOWED |
| SSN# |
This certificate may contain confidential or legally privileged information and is intended solely for the use of the individual or entity authorized to receive it. If you are not the intended recipient, disclosure, copying, distribution, or taking any action in reliance on the contents of this information is strictly prohibited and may be unlawful.
Attachment C
