Free F245-010-000 Statement for Compound Prescription - Washington

NO STAPLES IN BAR CODE AREA

Dept. of Labor and Industries PO Box 44269 Olympia WA 98504-4269

DO NOT WRITE IN SPACE

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Pharmacy name & address
L&I provider No. / NPI NCPDP NO.

STATEMENT FOR COMPOUND PRESCRIPTION
Instructions for completing form on the reverse side
Claim No. Soc. Sec. No. (For ID only) Worker's name (last, first, middle) Address City Bill date Employer State ZIP

Is this a request to reimburse the injured worker? Is this a private insurance co-payment?

YES YES

NO 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) Prescription Number Compound drug code S/B Date of injury Date RX written Prescribing provider's name Date Rx filled Total No. of ingredients Antibiotic IV therapy Total parental nutrition Refill Number (0-99) Quantity Grams: Milliliters: Compounding time
Prescribing prov. no. (L&I #, license #, DEA # or NPI) Drug cost Dispensing fee Professional fee Prescription total

$ $ $ $

00990000000
Prescription filled for:

Doses: Dispense as written product selection code (DAW) (0, 1 or 6) Pain cocktail Other therapy

Topical preparation

COMPOUND ITEMIZATION
NDC/UPC Name

ATTACH ADDITIONAL ITEMIZATION OF OTHER INGREDIENTS IF MORE THAN 10 WERE USED

Strength

Quantity

(X)

Drug cost/unit /

(=)

Drug cost $ $ $ $ $ $ $ $ $ $

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
The injured worker has paid for the above services and prescription(s). Pharmacist's Signature / / / / / / / / /

X
When you submit this bill, you are certifying that the prescription information is correct. L&I must receive this statement within 12 months of the date of service or claim allowance .
F245-010-000 statement for compound prescription 01-2009

RESET

Instructions for completing "Statement for Compound Prescription" form
Do not complete this form for reimbursement of a private insurance co-payment. Call L&I at 1-800-848-0811 for instructions

Types of Insurance
STATE FUND INDUSTRIAL INSURANCE Claim numbers are six digits, beginning with a "B, C, F, G, H, J, K, L, M, N, P, X, Y or double alpha followed by 5 digits." Send bills for Industrial Insurance claims to: Department of Labor and Industries PO Box 44269 Olympia WA 98504-4269 CRIME VICTIMS Claim numbers are six digits beginning with a "V", or five digits proceeded by a "VA, VB, VC, VH, VJ, VK or VL." Send bills for Crime Victims claims to: Department of Labor and Industries PO Box 44520 Olympia WA 98504-4520

SELF-INSURANCE Claim numbers are six digits beginning with an "S, T or W." Department of Energy claims are now Self-Insured. Claim numbers are seven digits beginning with "7, 8 or 9." Send bills to the employer or their service company.

Pharmacy address changes
PHARMACY NAME AND ADDRESS: If any of this information changes, call 1-800-848-0811 immediately. (Simply indicating a new address on the bill will not change L&I's record of address for the provider.) For further information, find us at: www.Lni.wa.gov/claimsinsurance/providerpay/billing/provider

Prescription Information
L&I PROVIDER NUMBER / NPI: The specific Provider number or NPI issued to the pharmacy. NCPDP NO: The 7-digit number assigned by National Council for Prescription Drug Programs. REIMBURSE INJURED WORKER: Place "X" in applicable box. S/B (SIDE OF BODY): Designate "L" (left), "R" (right) side of body or "B" (bilateral), to indicate location of injury. DATE OF INJURY: This is important and must be included. One worker may have several claims, so it is vital the proper claim be identified and charged for services provided. PRESCRIBING PROVIDER NUMBER (L&I#, LICENSE#, DEA# OR NPI): Provider number issued to the prescribing physician by L&I, a WA state license#, a DEA# or NPI. (not pharmacy's provider#). DRUG COST: Total charge for the filled prescription. REFILL NUMBER: Enter the refill number (0-99), if prescription is a refill other wise "0" to identify the original prescription. QUANTITY: The total units of medication prescribed. Use the (NCPDP) billing unit standard format, e.g., "each", "ml" or "gm". DISPENSING FEE: The fee for services provided by the pharmacist. TOTAL NUMBER OF INGREDIENTS: The number of NDC/UPC ingredients used in the prescription. DISPENSED AS WRITTEN PRODUCT SELECTION CODE: Code indicating whether or not the prescriber's instructions regarding generic substitution were followed. Valid values are: 0 = No product selection mandated; 1 = Substitution not allowed by prescriber; 6 = Override for emergency supply - This value is used only by in-state pharmacies when dispensing an emergency supply of a non-preferred drug prescribed by a non-endorsing practitioner.

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COMPOUNDING TIME: Time required to combine the ingredients in the prescription. PROFESSIONAL FEE: Fee for compounding time. PRESCRIPTION FILLED FOR: Place an "X" in the applicable box. TOTAL PRESCRIPTION COSTS: Total charge for the filled prescription. (Drug cost + professional fee + applicable tax). COMPOUND ITEMIZATION: Detail of the ingredients used in the prescription. REIMBURSE THE INJURED WORKER: Signature of pharmacist who supplied the prescription is required.

F245-010-000 statement for compound prescription

backer 01-2009