Pharmacy Billing Statement {WC-M4-PSYCH} | Pdf Fpdf Doc Docx | Colorado

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Pharmacy Billing Statement {WC-M4-PSYCH} | Pdf Fpdf Doc Docx | Colorado

Pharmacy Billing Statement {WC-M4-PSYCH}

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

Alternate TextLast updated: 7/7/2006

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DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers' Compensation PHARMACY BILLING STATEMENT Insurance Carrier Name and Address: Date: Invoice Number: Pharmacy Name and Address: Tax ID Number: Pharmacy NABP Number: Patient Information Name of Patient: Address: Address: Employer Name: Employer Information Date of Injury: Insurance Carrier Claim Number: Prescription Information Rx# RF# Prescriber Name NDC# QTY DS Date DAW Yes No Prescriber License # Drug Name and Dosage Total Price Rx# RF# Prescriber Name NDC# QTY DS Date DAW Yes No Total Price Prescriber License # Drug Name and Dosage Rx# RF# Prescriber Name NDC# QTY DS Date DAW Yes No Total Price Prescriber License # Drug Name and Dosage Rx# RF# Prescriber Name NDC# QTY DS Date DAW Yes No Total Price Prescriber License # Drug Name and Dosage To the Pharmacy: Submit this statement directly to the insurance carrier. C.R.S. Section 10-1-128(6)(a) states: "It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies." WC-M4 Rev 01/06 American LegalNet, Inc. www.USCourtForms.com

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