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Get WA F245-010-000 2010-2024

IN SPACE Soc. Sec. No. (For ID only) Claim No. Worker's name (last, first, middle) L&I provider No. / NPI Pharmacy name & address Address City NCPDP NO. State Employer Bill date Is this a request to reimburse the injured worker? YES NO Is this a private insurance co-payment? YES ZIP NO We do not reimburse for a private insurance co-payment. Call L&I at 1-800-848-0811 for instructions. PRESCRIPTION DETAIL DX Code (ICD-9) S/B Prescription Number Compound drug code Date of injur.

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