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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.



Formulario
F245-100-000
 
Pharmacy Companion Guide
This guide details the HIPAA ASC X12N 004010 format structure for 835 Pharmacy Remittance Advice and provides information regarding electronic billing to the department via Provider Express billing (PEB)

Manual
F245-400-000
 
Supplemental Agreement Third Party Pharmacy Provider
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.

Formulario
F249-021-000
 
Crime Victims Statement for Pharmacy Services

Used by Crime Victims Compensation Program providers to bill for pharmacy services. Crime Victims Compensation Program providers are required to bill using this form.



Formulario
F800-058-000
 
Statement for Compound Prescription

Bill form for use by pharmacies and home infusion companies to submit compound drug charges. This form is for drug charges only and is filled out by the pharmacist.



Formulario
F245-010-000
 
Crime Victims' Statement for Compound Prescription

Bill form for use by pharmacies and home infusion companies to submit compound drug charges for Crime Victims Compensation. This form is for drug charges only and is filled out by the pharmacist.



Formulario
F800-067-000
 





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