Supplemental Agreement Third Party Pharmacy Provider

Supplemental Agreement Third Party Pharmacy Provider - (Forms/Publications)
Document Information
  Get help downloading & printing files.   How to complete a fillable form.
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. See document above to download.
Keywords pharmacist, pharmacy, third party, third party claims
Languages English
Valid dates 03-2007
Contact information
Web pages Bill L&I for Pharmacy Services

End of main content, page footer follows.

Access Washington official state portal

© Washington State Dept. of Labor & Industries. Use of this site is subject to the laws of the state of Washington.