Pharmacy Invoice Template Example

Pharmacist’s Signature Date Date As provided by statues, this is to certify that the medication(s) was provided as outlined above and that no other or additional charge for such medication(s) has been or will be made against any person, firm or corporation.. Provider Name and Address MUST HAVE RECEIPTS ATTACHED ALL PHARMACY INVOICES SHOULD BE SUBMITTED WITHIN 30 DAYS FROM THE DATE OF SERVICE BRICKSTREET INSURANCE DOES NOT REIMBURSE INSURANCE CO-PAYMENTS BrickStreet Mutual Insurance  NorthStone Insurance  PinnaclePoint Insurance  SummitPoint Insurance INSTRUCTIONS FOR COMPLETING PHARMACY INVOICE BI-401 1.. CLAIMANT ADDRESS: Enter your full mailing address including street number, post office box or rural route number, city, state and zip code..