Statement for Pharmacy Services
See also
| Document Information | ||
|---|---|---|
 Get help downloading & printing files.  How to complete a fillable form. |
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| Title |
Statement for Pharmacy Services (A fillable form - 121 KB PDF)
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| Description | Bill form for prescription charges. May be used by a pharmacy to submit drug charges, or by a worker to request reimbursement for prescriptions paid out of pocket. See the General Provider Billing Manual (F248-100-000) for information on completing this form. |
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| Detail | ||
| Form number | F245-100-000 | |
| Availability | Order it |
|
| Keywords | drugs, pharmacist, self-insurance, self-insurer | |
| Languages | English | |
| Valid dates | 12-2012 | |
| Contact information |
Managing Injured Workers' Claims
Claims for Job Injuries |
|
| Related information | ||
| Documents | Statement for Compound Prescription Statement for Pharmacy Services - Crime Victims |
|
| Web pages | For Medical Providers | |
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