F245-100-000 Statement for Pharmacy Services 02-2019 Mail completed forms to: Department of Labor and Industries PO Box 44269 Olympia WA 98504 - 4269 S tatement F or Pharmacy Services We do not reimburse for private insurance co-payments. Read the instructions on the back before you start. Please print clearly. When you submit this bill, you are certifying that the prescription information is correct. We must receive this statement within 12 months of the date of service or claim allowance. Injured Worker Reimbursement: Receipts are required for injured worker reimbursement. Did you attach your receipts? Yes No Worker and Pharmacy Information: Worker222s SSN (for ID only) Claim number Pharmacy name & physical addres s Worker222s name (Last, First, Middle Initial) Worker222s mailing address City State Zip Code Pharmacy L&I provider number or NPI DEA number Pharmacy billing date Employer name Prescription Information: To be Completed by the Pharmacist Date Rx written Prescribing provider name Prescribing provider number Prescription number Date filled Refill number Days supply Quantity Dispense as written selection code (DAW 0,1, or 6) National Drug Code Drug name Drug utilization review codes CNFLT: INTRV: OUTCM: Remarks: Prescription clarification code Total Prescription Cost: Date Rx written Prescribing provider name Prescribing provider number Prescription number Date filled Refill number Days supply Quantity Dispense as written selection code (DAW 0,1, or 6) National Drug Code Drug name Drug utilization review codes CNFLT: INTRV: OUTCM: Remarks: Prescription clarification code Total Prescription Cost: Date Rx written Prescribing provider name Prescribing provider number Prescription number Date filled Refill number Days supply Quantity Dispense as written selection code (DAW 0,1, or 6) National Drug Code Drug name Drug utilization review codes CNFLT: INTRV: OUTCM: Remarks: Prescription clarification code Total Prescription Cost: Injured Worker Signature: These expenses are related to my worker222s compensation claim and I have not been reimbursed for them. I understand it is a crime to submit information I know is false. Injured Worker name (please print) Injured Worker222s signature American LegalNet, Inc. www.FormsWorkFlow.com F245-100-000 Statement for Pharmacy Services 02-2019 Complete each section. Injured Worker Reimbursement: Did you attach your receipts? Check the appropriate box for attaching receipt. Receipts are required for injured worker reimbursements. Send copies of the receipts only. Be sure to write your claim number on each rec eipt. Worker Information: Worker222s social security number Worker222s social security number. Used to verify claim number. Claim number Claim number prescription should be billed to. Worker222s name Worker222s legal name in the last, first, middle initial format. Worker222s mailing address Worker222s mailing address (can be a PO Box). Employer222s name Worker222s employer at the time of injury. Pharmacy Information: Pharmacy name & address Pharmacy name and physical location. Pharmacy L&I provider number or N PI Pharmacy222s L&I provider number or L&I registered NPI. NCPDC number National Council for Prescription Drug Programs number. Pharmacy billing date Date prescription was filled. Prescription Information: Date R x written Date prescription was written. Prescribing provider name Prescribing provider222s name. Prescribing provider number Give one of the following numbers for the prescription provider: L&I provider number; NPI; Washington state license number; or DEA number. Prescription number Prescription number. Date filled Date prescription filled. Refill number If the prescription is a refill, enter refill number (0 - 99). If original prescription, enter 2230224. Days supply Number of days supply. If the directions say 223as needed224 or has a dose range, estimate days supply using maximum dosage per day. Quantity Total units of medication prescribed. Use the NCPDP billing unit standard format such as 223each224, 223ml224, or 223gm224. Dispense as written selection code 0 = no product selection mandated 1 = substitution not allowed by prescriber 6 = override for emergency supply. For instate pharmacies only when dispensing emergency supply of a non-preferred drug prescribed by a non - endorsing provider. National Drug Code National drug identification code. The code mu st be entered in a 5 - 4 - 2 format. For example, NDC code 0005-3250-23 should be entered 00005 3250 23. NDC code 50419 127 12 should be entered 501419 0127 12. Drug name Drug name. Drug utilization review codes Enter the appropriate conflict, intervention, and outcome codes. Remarks Pertinent information related to prescription. Prescription clarification code Enter appropriate value for a refill - too - soon. Total prescription cost Total cost of prescription. Injured Worker Signature: Injured worker signature Injured worker signature is only required if the worker is requesting reimbursement. Need more help or more information? Go to www.Lni.wa.gov and click on Medical Providers or call the Preferred Drug Line at 888-443-6798. Need more forms? Go to www.Lni.wa.gov and click on Get a Form or Publication. American LegalNet, Inc. www.FormsWorkFlow.com