Member Services

Instructions

Prescription Drug - Claim Form

PLEASE PRINT ALL SECTIONS

1. This form is to be used to claim prescription drug benefits provided to eligible subscribers and their dependents.
2. Please complete all sections. We need all the information requested to process your claims.
3. Copy subscriber and patient information from your HIP Identification Card
   -see example below.
   
   
4. Have your pharmacist complete sections C, D1, D2, D3 and D4.
   Receipts must be attached.
5. Use a separate form for each patient. In addition, use a separate form for each pharmacy serving the patient.
6. Send the form to: HIP of Greater NY Pharmacy Services, 55 Water Street, New York, NY 10041-8190.