Our Pharmacy Benenfit Manager Processes
Daily Processed Rx Scripts
Transactions (Unlimited Scale)
Benefit Designs
Managed Member Pharmacy Spend
URAC Accelerated Pharmacy Benefit Manager (Highly Respected)
Notarized # 5XXX_XXXX
Claim Range: 05/26/2022 – 08/22/2023
Date Printed: 8/22/2023 5:15:15 PM
Patient: Ivan B Smartest
DOB: 02/22/1956
Produced for the Law Firm of:
(Example) xxx Attorneys at Law
Representing Attorney: xxxx
Case Number: x01-0101xx
Certification of Billing Records
| Fill Date | Medication | NDC | Qty | Days supply | Amount | Rx Number | Pharmacy | Physician |
|---|---|---|---|---|---|---|---|---|
| 7/7/2022 | ORPHENADRINE ER 100 MG TABLET | 43386048024 | 30 | 30 | $76.01 | xxxxxxx | CVS Pharmacy | J.JONES MD |
| 6/7/2022 | ORPHENADRINE ER 100 MG TABLET | 43386048024 | 30 | 30 | $77.25 | xxxxxxx | CVS Pharmacy | J.JONES MD |
| 8/7/2022 | ORPHENADRINE ER 100 MG TABLET | 43386048024 | 30 | 30 | $81.74 | xxxxxxx | CVS Pharmacy | J.JONES MD |
| 9/7/2022 | ORPHENADRINE ER 100 MG TABLET | 43386048024 | 30 | 30 | $79.88 | xxxxxxx | CVS Pharmacy | J.JONES MD |
| 10/7/2022 | ORPHENADRINE ER 100 MG TABLET | 43386048024 | 30 | 30 | $83.90 | xxxxxxx | CVS Pharmacy | J.JONES MD |
| 11/7/2022 | ORPHENADRINE ER 100 MG TABLET | 43386048024 | 30 | 30 | $82.22 | xxxxxxx | CVS Pharmacy | J.JONES MD |
| 12/7/2022 | ORPHENADRINE ER 100 MG TABLET | 43386048024 | 30 | 30 | $82.22 | xxxxxxx | CVS Pharmacy | J.JONES MD |
| 1/7/2023 | ORPHENADRINE ER 100 MG TABLET | 43386048024 | 30 | 30 | $85.53 |
xxxxxxx | CVS Pharmacy | J.JONES MD |
Your confidential health information is legally protected by law under the HIPPA statues.
It must be strictly used only under the guidance of all the HIPPA protections.
Your accumulated Personal History spreadsheet can only be used by your authorized personal representative or confidentially by parties who have been authorized to use your information. For Example: It may be used in your case and to assist the Court System that may be adjudicating your case in a HIPPA compliant format. (You, for Authorized, Attorneys, Insurance Companies, IRS Medical Expenses)
If you have received this information and are not an authorized party, or if you believe this message has reached you in error, it is imperative that you destroy the information immediately. Following the destruction, please notify us at your earliest convenience to confirm that the action has been completed.
