Get Wa F245-100-000 2019-2025

The WA F245-100-000 form is essential for requesting reimbursement for pharmacy services related to workers' compensation claims in Washington. This guide provides a clear and supportive walkthrough on how to accurately complete this form online, ensuring users understand each component and its significance.

Follow the steps to successfully complete your pharmacy services form.

1. Press the ‘Get Form’ button to access the WA F245-100-000 form online and open it in the form editor.
2. Fill in the worker's social security number; this is used solely for identification purposes.
3. Provide the claim number associated with the prescription; ensure accuracy.
4. Enter the worker's legal name, formatted as last name, first name, and middle initial.
5. Input the worker's mailing address, which may include a PO Box if applicable.
6. List the employer's name at the time of the injury.
7. Fill in the pharmacy name and physical address where the services were rendered.
8. Include the pharmacy's L&I provider number or National Provider Identifier (NPI).
9. Indicate the billing date for the pharmacy services.
10. Proceed to the Prescription Information section; here, the pharmacist will provide details like the date the prescription was written and the prescribing provider's name.
11. Enter the prescription number along with the date it was filled and the refill number, if applicable.
12. Complete the days supply field by estimating based on the prescribed dosage.
13. Input the total quantity of medication prescribed according to the standard billing unit format.
14. Indicate the dispense as written selection code; options are 0, 1, or 6, based on what applies.
15. List the National Drug Code (NDC), ensuring it follows the required 5-4-2 format.
16. Enter the drug name and any relevant drug utilization review codes.
17. Include any remarks or prescription clarification codes as necessary.
18. Finally, confirm the total prescription cost as indicated by the pharmacy.
19. The injured worker must sign the form, certifying that they have not been reimbursed for these expenses.
20. Review the completed form for accuracy, then save changes, download, print, or share the form as needed.

Start completing your WA F245-100-000 form online today to ensure timely reimbursement for pharmacy services.