Statement for Pharmacy Services

Statement for Pharmacy Services - (Forms/Publications)
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Title Statement for Pharmacy Services (A fillable form - 121 KB PDF)

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.

Form number F245-100-000
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Keywords drugs, pharmacist, self-insurance, self-insurer
Languages English
Valid dates 12-2012
Contact information Managing Injured Workers' Claims
Claims for Job Injuries
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