Any person who knowingly and with intent to defraud, injure, or deceive any insurance company, submit a claims or application containing any materially false, deceptive, incomplete or misleading information pertaining to such claim may be committing a fraudulent insurance act which is a crime and may subject such person to criminal or civil penalties, including fines and/or imprisonment, or denial of benefits. I certify that the medication(s) for which reimbursement is requested were received for use by the member above, and that I (or the member, if not myself) am eligible for prescription drug benefits. I also certify that the medications received were not for treatment of an on-the-job injury.