DWC066 Texas Department of Insurance Division of Workers' Compensation Statement of Pharmacy Services Send form to workers' compensation insurance carrier I. COVERAGE VERIFICATION In accordance with 28 Texas Administrative Code (TAC) §134.501, I affirm that I have verified the workers' compensation insurance coverage for this employer, confirmed that a work-related injury of the employee named below has been reported to the employer for the listed date of injury, and have kept documentation regarding the means of verification/confirmation on file. II. GENERAL INFORMATION 1. Pharmacy Name, Address and Telephone Number 2. Date of Billing (mm/dd/yyyy) 3. Pharmacy National Provider Identification Number 4. Remit Payment To (if different from above) 5. Invoice Number 6. Payee Federal Employer Identification Number 7. Insurance Carrier Name 8. Employer Name, Address and Telephone Number 9. Injured Employee Name, Address and Telephone Number 10. Injured Employee Social Security Number 11. Date of Injury (mm/dd/yyyy) 12. Injured Employee Date of Birth (mm/dd/yyyy) 13. Prescribing Doctor Name, Address and Telephone Number 14. Prescribing Doctor National Provider Identification Number 15. Insurance Carrier Claim Number (if known) 16. TDI-DWC Claim Number (if known) III. PRESCRIPTION DRUG INFORMATION 17. Dispensed 20. Date Filled Generic Name Brand 18. Generic Available? 22. Name Brand NDC YES NO 19. Dispensed As Written Code: 24. Days Supply 25. Fill Number 26. Paid by Employee 21. Generic NDC 23. Quantity 27. Drug Name and Strength 28. Prescription Number 29. Amount Billed 30. Preauthorization Number (if applicable) 17. Dispensed 20. Date Filled Generic Name Brand 18. Generic Available? 22. Name Brand NDC YES NO 19. Dispensed As Written Code: 24. Days Supply 25. Fill Number 26. Paid by Employee 21. Generic NDC 23. Quantity 27. Drug Name and Strength 28. Prescription Number 29. Amount Billed 30. Preauthorization Number (if applicable) Additional information on required and optional data requirements can be found in 28 TAC §133.10. American LegalNet, Inc. www.FormsWorkFlow.com DWC066 Rev. 12/11