STATE OF MONTANA - DEPARTMENT OF PUBLIC HEALTH & HUMAN SERVICES
FOR USE BY PHARMACIES PLEASE TYPE OR PRINT FORM NO. MA-5
 
COMPOUND DRUG CLAIM
 
.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 III - CLAIM INFORMATION
12a. Prescription Number
12b. Level of Effort
12c. Prior Authorization Number
12d. Other Coverage Costs
12e. Total Charges
$
12f. Other Coverage Amount
$
12g. Patient Paid
$
12h. Net Billed
$
SECTION IV - COMPOUND INGREDIENTS
1. Ingredient NDC Ingredient Quantity Ingredient Cost
$
2. Ingredient NDC Ingredient Quantity Ingredient Cost
$
3. Ingredient NDC Ingredient Quantity Ingredient Cost
$
4. Ingredient NDC Ingredient Quantity Ingredient Cost
$
5. Ingredient NDC Ingredient Quantity Ingredient Cost
$
6. Ingredient NDC Ingredient Quantity Ingredient Cost
$
7. Ingredient NDC Ingredient Quantity Ingredient Cost
$
8. Ingredient NDC Ingredient Quantity Ingredient Cost
$
9. Ingredient NDC Ingredient Quantity Ingredient Cost
$
10. Ingredient NDC Ingredient Quantity Ingredient Cost
$
12i. Prior Authorization Number
12j. Other Coverage Code
12k. Total Charges
$
12l. Other Coverage Amount
$
12m. Patient Paid Amount
12n. Net Billed
12o. 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.
Signature - Pharmacist or Dispensing Physician
 
Date Signed
 
Last updated April 29, 2008
Any previous versions are obsolete