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How to fill out the Po Box 44269 Olympia WA 98504 online
Filling out the form for pharmacy services can be a straightforward process if you follow the right steps. This guide provides clear instructions to help you complete the Po Box 44269 Olympia WA 98504 form accurately and efficiently.
Follow the steps to complete your pharmacy services form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by completing the injured worker reimbursement section. Confirm if you have attached receipts, as they are required for reimbursement.
- Next, fill out the worker information. Enter the worker's social security number, claim number, legal name in the format of last, first, middle initial, and mailing address.
- Provide information about the worker's employer, including their name.
- In the pharmacy information section, complete the pharmacy name and physical address. Include the pharmacy's L&I provider number or NPI.
- Record the pharmacy billing date, ensuring the date is accurate.
- Fill out the prescription information. This section requires details such as the date the prescription was written, the name of the prescribing provider, and their provider number.
- Include the prescription number, date filled, refill number (if applicable), days supply, and quantity.
- List the drug name and select the dispense as written code. Additionally, enter the national drug code in the required format.
- Document any necessary drug utilization review codes and remarks to provide further context.
- Calculate and enter the total prescription cost in the designated area.
- Finally, the injured worker must sign the form, certifying the expenses are related to their worker’s compensation claim and that information provided is accurate.
- Once all sections are complete, save changes, then proceed to download, print, or share the completed form as needed.
Complete your pharmacy services document online for efficient processing.
You generally have three years from the date of your injury to file an L&I claim in Washington state. It's crucial not to wait too long, as this can limit your options for receiving benefits. To clarify any questions, additional resources are located at Po Box 44269 Olympia Wa 98504.
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