Statement for Compound Prescription


Statement for Compound Prescription

Document Information
Get help downloading & printing files. How to complete a fillable form.
Title	Statement for Compound Prescription (A fillable form - 340 KB PDF)
Description	To have L&I reimburse an injured worker for costs associated with purchasing their compound prescriptions less any co-payment. This form is filled out by the pharmacist. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode.
Detail
Form number	F245-010-000
Availability	Order it
Keywords	drugs, pharmacist, pharmacy, prescriptions, reimbursement, self-insurance, self-insurer
Languages	English
Valid dates	01-2009
Contact information	Managing Injured Workers' Claims Claims for Job Injuries
Related information
Documents	Statement for Pharmacy Services
Web pages	For Medical Providers