STATE OF WYOMING DEPARTMENT OF WORKFORCE SERVICES WORKERS' COMPENSATION DIVISION CLAIM FOR PHARMACY / MEDICAL SUPPLIES 307-777-7441 PLEASE PRINT OR TYPE IN BLACK INK Injured Worker Information CASE # SSN # Date of Birth DATE OF INJURY NAME ADDRESS CITY EMPLOYER ADDRESS CITY STATE ZIP STATE ZIP Payee Information FEDERAL TAX ID# OR SSN# PAYEE NAME **ADDRESS CITY PHONE # ( ) STATE ZIP Required for payment INVOICE / PATIENT # NABP# / NCPDP# NOTE: Do not use abbreviations or symbols for drugs or supplies. Itemize supplies dispensed. Provide name of prescribing physician. Payments for drugs will be based upon the Division Rules, Chapter 9 and 10. Date Dispensed National Drug Code Name of Drug or Item Qty. TOTAL CHARGES Invoice or RX # DAW Code / Refill Doctor's Name DEA # Days Supply ** Pharmacy Name & Location REQUIRED, if different than Payee Name: TOTAL: For Division Use Only I hereby certify under penalty of perjury, that all items billed above were rendered solely on account of the original compensable injury and are true, accurate and complete to the best of my knowledge. Payee's Signature (required) INSTRUCTIONS FOR FILING: Date Submit billing no later than the 30th of each month for prior month's services or CLAIM MAY BE DENIED MAIL ORIGINAL TO: Division of Workers' Compensation PO Box 20070 Cheyenne, WY 82003-7001 RX WSCD-10 (Rev 12/11) American LegalNet, Inc. www.FormsWorkFlow.com