Itemized Statement Of Charges For Drugs {25P}

FORM 25P 10/2017 PAGE 1 OF 1 NCIC - MEDICAL BILLING SECTION 1236 MAIL SERVICE CENTER RALEIGH, NC 27699-1236 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688- 8349 WEBSITE: HTTP:/ / WWW.IC.NC.GOV / FORM 25P North Carolina Industrial Commission IC File # I TEMIZED STATEMENT OF CHARGES FOR DRUGS Emp. Code # Carrier Code # The Use of This Form Is Required Under the Provisions of the Workers' Compensation ActEmployer FEIN ( ) Employee222s Name Employer's Name Telephone Number A ddress Employer222s Address City State Zip City State ZipInsurance Carrier ( ) ( ) Home Telephone Work TelephoneCarrier's Address City State Zip XXX-XX- M F / / ( ) ( ) Last 4 Digits of SSN Sex Date of Birth Carrier's Telephone Number Fax Number DATE DRUG STORE CITYNAME OF DRUG & PRESCRIPTION NO.PHYSICIAN A MOUNT TOTAL $ This is to certify that the drugs listed above were related to my workers' compensation injury. (Receipts must be furnished for carrier's file) Employee signature Carrier222s approval Reimburse emplo y ee Yes no EMPLOYEE: Mail your bill in duplicate promptly to employer and/or insurance carrie r Reimburse dru g store Yes no EMPLOYER OR CARRIER/ADMINISTRATOR: DRUGS MAY BEREIMBURSED DIRECTLY TO THE EMPLOYEE OR DRUG STORE.IT IS NOT NECESSARY TO SUBMIT BILLS TO THE COMMISSIONFOR APPROVAL. PAY AND RETAIN COPY IN CARRIER222S FILE. American LegalNet, Inc. www.FormsWorkFlow.com