Dwc 066 form 2025

1. Click ‘Get Form’ to open the dwc 066 form in the editor.
2. Begin with Section I: Coverage Verification. Confirm that you have verified the workers’ compensation insurance coverage for the employer and document this verification.
3. Move to Section II: General Information. Fill in the pharmacy name, address, and telephone number, followed by the date of billing and pharmacy national provider identification number.
4. Continue completing fields such as remit payment details, invoice number, payee federal employer identification number, and insurance carrier name.
5. Provide information about the injured employee including their name, address, social security number, date of injury, and date of birth.
6. In Section III: Prescription Drug Information, detail each dispensed drug including its name, strength, quantity, days supply, and any applicable NDC numbers.
7. Review all entries for accuracy before saving or sending your completed form directly from our platform.

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