Mail completed forms to: Department of Labor and Industries PO Box 44520 Olympia WA 98504-4520 CRIME VICTIMS STATEMENT FOR PHARMACY SERVICES · · Read the instructions on the back before you start. When you submit this bill, you are certifying that the prescription information is correct. Request to reimburse the claimant (Pharmacist signature required below) This is an insurance co-payment reimbursement. Claimant's SSN (for ID only) Claim number Pharmacy name & physical address Claimant's name (Last, First, Middle Initial) Claimant's mailing address City State Pharmacy billing date Prescribing provider number Days supply Quantity Dispense as written selection code (DAW 0,1, or 6) Zip Code Pharmacy L&I provider number or NPI Date Rx written Prescription number National Drug Code Remarks: Prescribing provider name Date filled DEA number Refill number Drug name Drug utilization review codes CNFLT: INTRV: Prescription clarification code Total Prescription Cost: OUTCM: Date Rx written Prescription number National Drug Code Remarks: Prescribing provider name Date filled Refill number Days supply Quantity Prescribing provider number Dispense as written selection code (DAW 0,1, or 6) Drug name Drug utilization review codes CNFLT: INTRV: Prescription clarification code Total Prescription Cost: OUTCM: Date Rx written Prescription number National Drug Code Remarks: Prescribing provider name Date filled Refill number Days supply Quantity Prescribing provider number Dispense as written selection code (DAW 0,1, or 6) Drug name Drug utilization review codes CNFLT: INTRV: Prescription clarification code Total Prescription Cost: OUTCM: The claimant has paid for the above services and prescriptions. Pharmacist name (please print) Pharmacist signature F800-058-000 Statement for Pharmacy Services 09-2013 American LegalNet, Inc. www.FormsWorkFlow.com Complete each section. Claimant Information: Claimant's social security number Claim number Claimant's name Claimant's mailing address Pharmacy Information: Pharmacy name & address Pharmacy L&I provider number or NPI NCPDC number Pharmacy billing date Prescription Information: Date Rx written Prescribing provider name Prescribing provider number Prescription number Date filled Refill number Days supply Quantity Dispense as written selection code Claimant's social security number. Used to verify claim number. Claim number prescription should be billed to. Claimant's legal name in the last, first, middle initial format. Claimant's mailing address (can be a PO Box). Pharmacy name and physical location. Pharmacy's L&I provider number or L&I registered NPI. National Council for Prescription Drug Programs number. Date prescription was filled. Date prescription was written. Prescribing provider's name. Give one of the following numbers for the prescription provider: L&I provider number; NPI; Washington state license number; or DEA number. Prescription number. Date prescription filled. If the prescription is a refill, enter refill number (0-99). If original prescription, enter "0". Number of days supply. If the directions say "as needed" or has a dose range, estimate days supply using maximum dosage per day. Total units of medication prescribed. Use the NCPDP billing unit standard format such as "each", "ml", or "gm". 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 identification code. The code must 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. Enter the appropriate conflict, intervention, and outcome codes. Pertinent information related to prescription. Enter appropriate value for a refill-too-soon. Total cost of prescription. National Drug Code Drug name Drug utilization review codes Remarks Prescription clarification code Total prescription cost Need more help or more information? Go to www.LNI.wa.gov and click on Help for Crime Victims. Need more forms? Go to www.Lni.wa.gov and click on Get a Form or Publication. F800-058-000 Statement for Pharmacy Services 09-2013 American LegalNet, Inc. www.FormsWorkFlow.com