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Prescription Drug Reimbursement Form Y0082_5041_16_CI_128_E In order to process your request as timely as possible.  The pharmacy’s original invoice/receipt… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Médico Facilidad Medicare ID: Nombre del proveedor _________________________________ Contacto _______________________________ NPI Proveedor que brindó servicio _______________________________ Teléfono _______________________________ NPI Proveedor… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Triple S Advantage PO Box 11320 San Juan, PR 00922 Relevo de Responsabilidad _______________________________ Numero de Identificación Medicare ________________________________ Nombre… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Physician Facility Medicare ID: Provider Name _________________________________ Contact ____________________________________ Rendering Provider NPI _________________________________ Telephone ____________________________________ Billing Provider NPI _________________________________ Fax… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Triple S Advantage PO Box 11320 San Juan, PR 00922 Waiver of Liability _______________________________ Medicare Identification Number ________________________________ Member’s Name… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Face to Face Examination Pág 1 de 2 Rev. 09/2014 Face to Face (Versión Español) Nombre del Paciente:__________________________________ Número de… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Rev. 3/2015 Certificado de Necesidad Médica Silla de Baño Sección A: Información General Certificación: Inicial: Revisado: ____/____/____ Nombre del Paciente:… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Rev. 3/2015 Certificado de Necesidad Médica Monitor de Presión Arterial (Esfigmomanómetro) Sección A: Información General Certificación: Inicial: Revisado: ____/____/____ Nombre… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Rev. 3/2015 Certificado de Necesidad Médica No-Emergente Transportación en Ambulancia Sección A: Información General (Esta parte deberá ser completada por… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)

Favor enviar por fax al 787-993-3265 Triple-S Advantage es una organización de cuidado coordinado (HMO, por sus siglas en inglés)… (Search: 1 in body, 1 in title, 1 in categories, 1 in tags, 1 in other taxonomies, 1 in comments. Score: 20.5)