Loading
Form preview picture

Get Dwc 66

DWC066 Texas Department of Insurance Division of Workers Compensation Statement of Pharmacy Services Send form to workers compensation insurance carrier I. COVERAGE VERIFICATION In accordance with 28 Texas Administrative Code TAC 134. 501 I affirm that I have verified the workers compensation insurance coverage for this employer confirmed that a work-related injury of the employee named below has been reported to the employer for the listed date of injury and have kept documentation regarding the means of verification/confirmation on file. II. GENERAL INFORMATION 1. Pharmacy Name Address and Telephone Number 2. Date of Billing mm/dd/yyyy 3. Pharmacy National Provider Identification Number 4. Remit Payment To if different from above 5. Invoice Number 6. Payee Federal Employer Identification Number 7. Insurance Carrier Name 8. Employer Name Address and Telephone Number 9. Injured Employee Name Address and Telephone Number 11. Date of Injury mm/dd/yyyy 13. Prescribing Doctor Name Address and Telephone Number 16. TDI-DWC Claim Number if known III. PRESCRIPTION DRUG INFORMATION 17. Dispensed 20. Date Filled Generic Name Brand 18. Generic Available 21. Generic NDC 22. Name Brand NDC YES 23. Quantity 26. Paid by Employee 28. Prescription Number 27. Drug Name and Strength 24. Days Supply 25. Fill Number 29. Amount Billed 30. Preauthorization Number if applicable Additional information on required and optional data requirements can be found in 28 TAC 133. COVERAGE VERIFICATION In accordance with 28 Texas Administrative Code TAC 134. 501 I affirm that I have verified the workers compensation insurance coverage for this employer confirmed that a work-related injury of the employee named below has been reported to the employer for the listed date of injury and have kept documentation regarding the means of verification/confirmation on file. II. GENERAL INFORMATION 1. Pharmacy Name Address and Telephone Number 2. Date of Billing mm/dd/yyyy 3. II. GENERAL INFORMATION 1. Pharmacy Name Address and Telephone Number 2. Date of Billing mm/dd/yyyy 3. Pharmacy National Provider Identification Number 4. Remit Payment To if different from above 5. Invoice Number 6. Pharmacy National Provider Identification Number 4. Remit Payment To if different from above 5. Invoice Number 6. Payee Federal Employer Identification Number 7. Insurance Carrier Name 8. Employer Name Address and Telephone Number 9. Payee Federal Employer Identification Number 7. Insurance Carrier Name 8. Employer Name Address and Telephone Number 9. Injured Employee Name Address and Telephone Number 11. Date of Injury mm/dd/yyyy 13. Prescribing Doctor Name Address and Telephone Number 16. Injured Employee Name Address and Telephone Number 11. Date of Injury mm/dd/yyyy 13. Prescribing Doctor Name Address and Telephone Number 16. TDI-DWC Claim Number if known III. PRESCRIPTION DRUG INFORMATION 17. Dispensed 20. Date Filled Generic Name Brand 18. TDI-DWC Claim Number if known III. PRESCRIPTION DRUG INFORMATION 17. Dispensed 20. Date Filled Generic Name Brand 18. Generic Available 21. Generic NDC 22. Name Brand NDC YES 23. Quantity 26. Paid by Employee 28. Prescription Number 27.

How It Works

tdi rating
4.8Satisfied
47 votes

Tips on how to fill out, edit and sign Prescribing online

How to fill out and sign Verification online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

The times of terrifying complex tax and legal documents are over. With US Legal Forms the entire process of submitting official documents is anxiety-free. The leading editor is already at your fingertips providing you with various beneficial instruments for completing a Dwc 66. The following tips, together with the editor will help you through the whole process.

  1. Select the Get Form button to start filling out.
  2. Switch on the Wizard mode in the top toolbar to obtain extra suggestions.
  3. Fill every fillable field.
  4. Ensure that the information you fill in Dwc 66 is updated and accurate.
  5. Include the date to the sample with the Date function.
  6. Click the Sign tool and create a signature. Feel free to use 3 available alternatives; typing, drawing, or capturing one.
  7. Make sure that every field has been filled in properly.
  8. Select Done in the top right corne to save or send the document. There are several alternatives for getting the doc. As an instant download, an attachment in an email or through the mail as a hard copy.

We make completing any Dwc 66 more convenient. Get started now!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Applicable FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to Dwc 66

  • DWC066
  • Payee
  • tdi
  • DWC
  • III
  • remit
  • applicable
  • affirm
  • prescribing
  • dispensed
  • billed
  • verification
  • Invoice
  • II
  • optional
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.