Itemized Statement Of Charges For Drugs {25P} | Pdf Fpdf Docx | North Carolina

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Itemized Statement Of Charges For Drugs {25P} | Pdf Fpdf Docx | North Carolina

Itemized Statement Of Charges For Drugs {25P}

This is a North Carolina form that can be used for Workers Comp.

Alternate TextLast updated: 4/1/2019

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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.

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