Get Wa F245-010-000 2010-2026

The WA F245-010-000 is essential for submitting a compound prescription for reimbursement through the Department of Labor and Industries. This guide provides straightforward instructions to help users fill out the form accurately and efficiently, ensuring their submissions are processed without delay.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the WA F245-010-000 form online and open it in your editing interface.
2. Begin by filling in the worker's name in the format of last name, first name, and middle initial. Ensure the spelling is correct for accurate identification.
3. Input the Social Security number for identification purposes; this field is for ID only, so include it carefully without any mistakes.
4. Locate the claim number section. Enter the six-digit claim number that begins with the appropriate letters as specified for your type of claim.
5. Fill in the pharmacy name and address, including the street address, city, state, and ZIP code. This ensures proper processing by the Department of Labor and Industries.
6. Indicate whether this form is for reimbursement to the injured worker or if it is a private insurance co-payment by selecting 'YES' or 'NO' for the relevant questions. Note that private insurance co-payments are not reimbursed.
7. In the prescription detail section, fill in the diagnosis code and all other required fields including the prescription number, compound drug code, and dates for injury and prescription written. Make sure to have accurate information to prevent delays.
8. List the total number of ingredients used in the prescription, as well as the dispensing fee, professional fee, and drug cost, ensuring that all amounts are correctly calculated and entered.
9. For the compound itemization, fill in the information for each ingredient used, including NDC/UPC, strength, quantity, and drug cost per unit. Make sure to detail all applicable components as needed.
10. Once all information is correctly filled out, review it thoroughly. Then, save changes, and you can choose to download, print, or share the completed form with the relevant parties.

Start filling out the WA F245-010-000 online to ensure your compound prescription is processed promptly.