Get Wa F245-010-000 2014-2026

Filling out the WA F245-010-000 form, also known as the Statement for Compound Prescription, is a crucial step in the reimbursement process for prescriptions. This guide will provide you with detailed, step-by-step instructions to complete the form accurately and efficiently.

Follow the steps to successfully complete the online form.

1. To begin, click the ‘Get Form’ button to access the WA F245-010-000 form. This will open the document for you to fill out.
2. Enter the pharmacy name and physical address in the designated fields. This information is essential for processing your claim.
3. Input the pharmacy’s L&I provider number or NPI. This number helps identify the pharmacy and ensure accurate processing.
4. Provide the pharmacy’s DEA number, which is necessary for controlled substances.
5. Enter the worker's social security number for identification purposes only. This information will be kept confidential.
6. Fill in the claim number associated with the worker’s case to link the prescription to the correct claim.
7. Input the worker's name, format it as Last, First, Middle Initial for clarity.
8. Provide the worker's mailing address, ensuring all information is accurate to avoid delays.
9. Specify the pharmacy billing date. This is the date on which the billing is submitted to the department.
10. Enter the employer's name for additional identification related to the worker's claim.
11. Complete the Prescription Detail section by entering the date the prescription was written and the name of the prescribing provider.
12. Enter the prescribing provider's number or NPI to verify their credentials.
13. Include the pharmacy’s prescription number, which refers to the specific prescription being filled.
14. Input the date the prescription was filled and, if applicable, the refill number.
15. Provide the days supply, which indicates how long the prescribed medication is intended to last.
16. Fill in the quantity of prescription items, following the NCPDP billing unit standard.
17. Specify the total number of ingredients used in the compound.
18. Choose the dispense as written selection code, indicating the prescriber's instructions regarding generic substitution.
19. Indicate the compounding time required to prepare the prescription.
20. Provide the total drug cost, dispensing fee, and professional fee for the services rendered.
21. Calculate the total prescription cost by summing the drug cost, professional fee, and any applicable taxes.
22. For the Compound Itemization section, fill out each column with NDC, name, strength, quantity, drug cost per unit, and total drug cost for each ingredient used.
23. If more than 10 drugs were included in the prescription, attach additional itemization as needed.
24. Finally, review the completed form for accuracy. Save the changes, download the document, print it, or share it as required.

Complete your WA F245-010-000 form online today to ensure timely processing of your prescription reimbursements.