STATE OF MONTANA - DEPARTMENT OF PUBLIC HEALTH & HUMAN SERVICES
FOR USE BY PHARMACIES PLEASE TYPE OR PRINT FORM NO. MA-5
.Return form to:
CLAIMS PROCESSING UNIT, Dept. MA-5, P.O. Box 8000, Helena, MT 59604
Telephone Number 1-800-624-3958, (406) 442-1837
SECTION I - PROVIDER INFORMATION
1. Name - Provider
2. NPI
3. Address - Provider (Street, City, State, Zip Code)
        
4. MHSP
    Medicaid
SECTION II - RECIPIENT INFORMATION
5. Cardholder Identification Number - Recipient
6.Name - Recipient (Last, First, Middle Initial)
7. Date of Birth - Recipient
SECTION III - CLAIM INFORMATION
8. Prescriber Number
9. Prescription Type
10. Date Filled
11. Refill
12. Compound
Yes No
13.NDC
| |
14. Days Supply
15. Qty
16. Charge
$
17. Unit Dose
Yes No
18. Prescription Number
19. DAW
20. Drug Description
21. Level of Effort
22. Sub Clar Code
23. Other Coverage Code
24. Total Charges
$
25. Other Coverage Amount
$
26. Patient Paid
$
27. Net Billed
$
 
8. Prescriber Number
9. Prescription Type
10. Date Filled
11. Refill
12. Compound
Yes No
13.NDC
| |
14. Days Supply
15. Qty
16. Charge
$
17. Unit Dose
Yes No
18. Prescription Number
19. DAW
20. Drug Description
21. Level of Effort
22. Sub Clar Code
23. Other Coverage Code
24. Total Charges
$
25. Other Coverage Amount
$
26. Patient Paid
$
27. Net Billed
$
 
8. Prescriber Number
9. Prescription Type
10. Date Filled
11. Refill
12. Compound
Yes No
13.NDC
| |
14. Days Supply
15. Qty
16. Charge
$
17. Unit Dose
Yes No
18. Prescription Number
19. DAW
20. Drug Description
21. Level of Effort
22. Sub Clar Code
23. Other Coverage Code
24. Total Charges
$
25. Other Coverage Amount
$
26. Patient Paid
$
27. Net Billed
$
 
8. Prescriber Number
9. Prescription Type
10. Date Filled
11. Refill
12. Compound
Yes No
13.NDC
| |
14. Days Supply
15. Qty
16. Charge
$
17. Unit Dose
Yes No
18. Prescription Number
19. DAW
20. Drug Description
21. Level of Effort
22. Sub Clar Code
23. Other Coverage Code
24. Total Charges
$
25. Other Coverage Amount
$
26. Patient Paid
$
27. Net Billed
$
29. Certification - I certify that the care, services and supplies itemized have been furnished, the amounts listed are due and, except as noted, no part thereof has been paid; payment of fees made in accordance with established schedules is accepted as payment in full. I further certify that the services(s) indicated above has/have been provided without regard to race, color, national origin, creed, sex, religion, political ideas, marital status, age or handicap. I here by agree to maintain and furnish on request to the Department, the Montana Medicaid Fraud Control Bureau, the U.S. DHHS, the Comptroller General of the U.S., or any of their duly authorized agents or representatives such records as necessary to disclose fully the extent of care, services, and supplies provided to individuals under the Montana Medical Assistance Program. I UNDERSTAND THAT PAYMENT OF THIS CLAIM WILL BE FROM FEDERAL AND STATE FUNDS, AND THAT ANY FALSIFICATION, OR CONCEALMENT OF A MATERIAL FACT, MAY BE PROSECUTED UNDER FEDERAL AND STATE LAWS. I hereby agree to comply with all rules and requirements pertaining to the Montana Medicaid Program, including but not limited to Title XIX of the Social Security Act, Montana Statues and the Administrative Rules of Montana. TOTAL
CHARGES
AMOUNT TO BE PAID
BY MEDICAID
Signature - Pharmacist or Dispensing Physician
 
Date Signed
 
AMOUNT TO BE PAID
BY RECIPIENT
Last updated April 29, 2008
Any previous versions are obsolete