Washington > Workers Comp > Crime Victims Compensation
Statement For Pharmacy Services (Crime Victims) F800-058-000 - Washington
| Statement For Pharmacy Services (Crime Victims) Form. This is a Washington form and can be used in Crime Victims Compensation Workers Comp . |
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Department of Labor and Industries Crime Victims Compensation Program PO Box 44520 Olympia WA 98504-4520 CRIME VICTIM STATEMENT FOR PHARMACY SERVICES Instructions for completing form on the reverse side. Claimant soc. sec. no. (for i.d. only) Claim no. DO NOT WRITE IN SPACE Claimant's name (last, first, middle) print or type Pharmacy name & address L&I Provider no. / NPI Claimant's mailing address City State ZIP NCPDP No Pharmacy billing date Is this a request to reimburse the claimant? Is this a private insurance co-payment? Prescription (RX) Information DX Code (ICD-9) S/B Prescription # National Drug Code Remarks YES YES NO NO Print Or Type All Information Prescribing Provider Number (L&I#, License#, DEA# or NPI) Date of injury Date Rx written Prescribing Provider's name Date Rx filled Refill Number (0 - 99) Days Supply Quantity (units) Dispensed as written product selection code (DAW) (0, 1 or 6) Drug name DUR codes CNFLT: (Refill-too-soon) INTRV: OUTCM: Total prescription cost $ Prescription clarification code DX Code (ICD-9) S/B Prescription # National Drug Code Remarks Date of injury Date Rx written Prescribing Provider's name Date Rx filled Prescribing Provider Number (L&I#, License#, DEA# or NPI) Refill Number (0 - 99) Days Supply Quantity (units) Dispensed as written product selection code (DAW) (0, 1 or 6) Drug name DUR codes CNFLT: (Refill-too-soon) INTRV: OUTCM: Total prescription cost $ Prescription clarification code DX Code (ICD-9) S/B Prescription # National Drug Code Remarks Date of injury Date Rx written Prescribing Provider's name Date Rx filled Prescribing Provider Number (L&I#, License#, DEA# or NPI) Refill Number (0 - 99) Days Supply Quantity (units) Dispensed as written product selection code (DAW) (0, 1 or 6) Drug name DUR codes CNFLT: (Refill-too-soon) INTRV: OUTCM: Total prescription cost $ Prescription clarification code Reimburse the claimant: Pharmacist's signature is required. The claimant 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. CVC must receive this statement within 12 months of the date of service, claim allowance or primary insurance payment decision. *If primary insurance has made payment, bill only the total that is patient responsibility. F800-058-000 crime victim statement for pharmacy services 08-2009 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for completing Statement for Pharmacy Services form Types of Insurance CRIME VICTIMS Claim numbers are six digits beginning with a "V", or five digits proceeded by a "VA, VB, VC, VH, VJ, VK, VL, VM, VN, or VS." Send bills for Crime Victims claims to: 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 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.) Pharmacy/Prescription Information L&I PROVIDER NUMBER: The specific Provider number / NPI issued to the pharmacy. NCPDP NO: The 7-digit number assigned by National Council for Prescription Drug Programs. REIMBURSE CLAIMANT: 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#). REFILL NUMBER: Enter the refill number (0-99) if prescription is a refill; otherwise "0" to identify the original prescription. DAYS SUPPLY: Using quantity dispensed and directions for use (sig) on the prescription, calculate the number of days supply. If the directions say as needed or have a dose range, estimate days supply using the maximum dosage per day. QUANTITY: The total units of medication prescribed. Use the (NCPDP) billing unit standard format, e.g., "each", "ml" or "gm". F800-058-000 crime victim statement for pharmacy services backer 08-2009 American LegalNet, Inc. www.FormsWorkFlow.com 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. NATIONAL DRUG CODE: National drug identification code. This code must be entered in a 5-4-2 format: e.g., if the NDC format listed in your pricing book is 0005-3250-23, enter 00005 3250 23. If the NDC format is 50419 127 12 enter 50419 0127 12. DUR CODES: Enter the appropriate conflict, intervention and outcome code. PRESCRIPTION CLARIFICATION CODE: Enter the appropriate value for a refill-too-soon. TOTAL PRESCRIPTION COSTS: Total charge for the filled prescription. (Drug cost + professional fee + applicable tax). REIMBURSE THE CLAIMANT: Signature of pharmacist who supplied the prescription is required.
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