Request For Injured Worker Outpatient Medication Reimbursement {BWC-1122}

BWC-1122 / C-17 - REQUEST FOR INJURED WORKER OUTPATIENT MEDICATION REIMBURSEMENT. This form is used for medication reimbursement. The medication must be written as a prescription and dispensed by an enrolled pharmacy. Medication bought at a physician’s office for at-home use is not reimbursable. A C-17 is not used for medical supplies, durable medical equipment, and other non-drug items. These items should be billed directly to the managed care organization (MCO). www.FormsWorkflow.com