Statement for Pharmacy Services

Document Information
  How to complete a fillable form.
Title Statement for Pharmacy Services

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.

Document number F245-100-000
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    Valid dates 08/2014
    Contact information Claims for Job Injuries , Managing Injured Workers' Claims
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