Statement for Pharmacy Services

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Title Statement for Pharmacy Services
Description

Bill form for prescription charges. May be used by a pharmacy to submit drug charges, or by a worker to request reimbursement for prescriptions paid out of pocket. See the General Provider Billing Manual (F248-100-000) for information on completing this form.

Document number F245-100-000
How to get this document
Keywords drugs, pharmacist, self-insurance, self-insurer
Alt Language(s)
Valid dates 12/2012
Contact information Claims for Job Injuries, Employer Services
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