Supplemental Agreement Third Party Pharmacy Provider
See also
| Document Information | ||
|---|---|---|
 Get help downloading & printing files.  How to complete a fillable form. |
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| Title |
Supplemental Agreement Third Party Pharmacy Provider (A fillable form - 119 KB PDF)
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| Description | This agreement is to define access, performance and legal requirements for third party pharmacy billers who submit bills to and receive payment from L&I on behalf of pharmacy providers. This agreement authorizes L&I to accept and remit monies due the Pharmacy using a third party pharmacy biller. | |
| Detail | ||
| Form number | F249-021-000 | |
| Availability | Online only. See document above to download. |
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| Keywords | pharmacist, pharmacy, third party, third party claims | |
| Languages | English | |
| Valid dates | 03-2007 | |
| Contact information | ||
| Web pages | Bill L&I for Pharmacy Services | |
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