Fillable Printable Form 245-100-000
Fillable Printable Form 245-100-000
Form 245-100-000
Mail completed forms to:
Department of Labor and Industries
PO Box 44269
Olympia WA 98504-4269
Statement For
Pharmacy Services
• We do not reimburse for private insurance co-payments.
• Read the instructions on the back before you start. Please print clearly.
• When you submit this bill, you are certifying that the prescription information is correct.
• We must receive this statement within 12 months of the date of service or claim allowance.
Injured Worker Reimbursement:
Receipts are required for injured worker reimbursement. Did you attach your receipts? Yes No
Worker and Pharmacy Information:
Worker’s SSN (for ID only)
Claim number
Pharmacy name & physical address
Worker’s name (Last, First, Middle Initial)
Worker’s mailing address
City State Zip Code
Pharmacy L&I provider number or NPI
DEA number
Pharmacy billing date
Employer name
Prescription Information:
Date Rx written
Prescribing provider name
Prescribing provider number
Prescription
number
Date filled
Refill number
Days supply
Quantity
Dispense as written selection code (DAW 0,1, or 6)
National Drug Code
Drug name
Drug utilization review codes
CNFLT: INTRV: OUTCM:
Remarks:
Prescription clarification
code
Total Prescription Cost:
Date Rx written
Prescribing provider name
Prescribing provider number
Prescription
number
Date filled
Refill number
Days supply
Quantity
Dispense as written selection code (DAW 0,1, or 6)
National Drug Code
Drug name
Drug utilization review codes
CNFLT: INTRV: OUTCM:
Remarks:
Prescription clarification
code
Total Prescription Cost:
Date Rx written
Prescribing provider name
Prescribing provider number
Prescription
number
Date filled
Refill number
Days supply
Quantity
Dispense as written selection code (DAW 0,1, or 6)
National Drug Code
Drug name
Drug utilization review codes
CNFLT: INTRV: OUTCM:
Remarks:
Prescription clarification
code
Total Prescription Cost:
Injured Worker Signature:
These expenses are related to my worker’s compensation claim and I have not been reimbursed for them. I
understand it is a crime to submit information I know is false.
Injured Worker name (please print)
Injured Worker’s signature
F245-100-000 Statement for Pharmacy Services 08-2014
RESET
Complete each section.
Injured Worker Reimbursement:
Did you attach your receipts?
Check the appropriate box for attaching receipt. Receipts are required
for injured worker reimbursements. Send copies of the receipts only. Be
sure to write your claim number on each receipt.
Worker Information:
Worker’s social security number
Worker’s social security number. Used to verify claim number.
Claim number
Claim number prescription should be billed to.
Worker’s name
Worker’s legal name in the last, first, middle initial format.
Worker’s mailing address
Worker’s mailing address (can be a PO Box).
Employer’s name
Worker’s employer at the time of injury.
Pharmacy Information:
Pharmacy name & address
Pharmacy name and physical location.
Pharmacy L&I provider number or
NPI
Pharmacy’s L&I provider number or L&I registered NPI.
NCPDC number
National Council for Prescription Drug Programs number.
Pharmacy billing date
Date prescription was filled.
Prescription Information:
Date Rx written
Date prescription was written.
Prescribing provider name
Prescribing provider’s name.
Prescribing provider number
Give one of the following numbers for the prescription provider: L&I
provider number; NPI; Washington state license number; or DEA
number.
Prescription number
Prescription number.
Date filled
Date prescription filled.
Refill number
If the prescription is a refill, enter refill number (0-99). If original
prescription, enter “0”.
Days supply
Number of days supply. If the directions say “as needed” or has a dose
range, estimate days supply using maximum dosage per day.
Quantity
Total units of medication prescribed. Use the NCPDP billing unit
standard format such as “each”, “ml”, or “gm”.
Dispense as written selection code
0 = no product selection mandated
1 = substitution not allowed by prescriber
6 = override for emergency supply. For instate pharmacies only when
dispensing emergency supply of a non-preferred drug prescribed by a
non-endorsing provider.
National Drug Code
National drug identification code. The code must be entered in a 5-4-2
format. For example, NDC code 0005-3250-23 should be entered 00005
3250 23. NDC code 50419 127 12 should be entered 501419 0127 12.
Drug name
Drug name.
Drug utilization review codes
Enter the appropriate conflict, intervention, and outcome codes.
Remarks
Pertinent information related to prescription.
Prescription clarification code
Enter appropriate value for a refill-too-soon.
Total prescription cost
Total cost of prescription.
Injured Worker Signature:
Injured worker signature
Injured worker signature is only required if the worker is requesting
reimbursement.
Need more help or more information?
Go to www.Lni.wa.gov and click on Medical Providers or call the Preferred Drug Line at 888-443-6798.
Need more forms? Go to www.Lni.wa.gov and click on Get a Form or Publication.
F245-100-000 Statement for Pharmacy Services 08-2014
