Pharmacy Insurance Billing Information Form

ℹ️ Why We Need This Information

To process your prescription through your insurance, our pharmacy requires specific identification numbers from your prescription drug insurance card. These numbers help us communicate electronically with your insurance company to verify your coverage and submit claims on your behalf.

BIN (Bank Identification Number) A 6-digit number that routes your claim to the correct insurance processor

PCN (Processor Control Number) Identifies the specific plan or program within the processor's system

Member/Recipient ID Your unique identifier that links to your specific insurance coverage

Rx Group Number Identifies your employer group or specific benefit plan

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Where to Find These Numbers These numbers are typically found on the front of your prescription drug insurance card. Look for labels such as "BIN," "PCN," "RxBIN," "RxPCN," "ID," "Member ID," "Rx Grp," or "Group." If you have separate medical and pharmacy cards, please use the pharmacy-specific card.

Patient Information

Patient Full Name *

Date of Birth *

Insurance Billing Numbers

BIN Number *

Usually labeled as "BIN" or "RxBIN" (6 digits)

PCN Number

May be labeled "PCN" or "RxPCN" — sometimes blank

Member / Recipient ID Number *

Also called "ID," "Subscriber ID," or "Cardholder ID"

Rx Group Number

May be labeled "Grp," "Rx Grp," or "Group"

Coverage Information

Relation to Primary Cardholder *

Self

Spouse

Child

Other

Primary Cardholder Name (if not self)