Supplemental Agreement Third Party Pharmacy Provider

Document Information
  How to complete a fillable form.
Title Supplemental Agreement Third Party Pharmacy Provider

This agreement is to define access, performance and legal requirements for third party pharmacy billers who submit bills to and receive payment from L&I on behalf of pharmacy providers. This agreement authorizes L&I to accept and remit monies due the Pharmacy using a third party pharmacy biller.

Document number F249-021-000
How to get this document
Alt Language(s)
Valid dates 03/2007
Contact information
Websites Bill L&I for Pharmacy Services

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