Supplemental Agreement Third Party Pharmacy Provider
 

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Title Supplemental Agreement Third Party Pharmacy Provider (A fillable form - 119 KB PDF)
Description 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.
Detail
Form number F249-021-000
Availability Online only
Keywords pharmacist, pharmacy, third party, third party claims
Languages English
Valid dates 03-2007
Contact information
Web pages Bill L&I for Pharmacy Services

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