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Compounding record template

Compound prescription form 2026

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The document is a Statement for Compound Prescription issued by the Department of Labor and Industries in Washington. It outlines the requirements for submitting a bill for compounded prescriptions, including necessary information such as worker and pharmacy details, prescription specifics, and costs associated with the drugs. It emphasizes that reimbursement does not cover private insurance co-payments and must be submitted within 12 months of service.

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Click ‘Get Form’ to open the compound prescription form in the editor.
Begin by entering the pharmacy name and physical address in the designated fields. This information is crucial for processing your claim.
Fill in the pharmacy’s L&I provider number or NPI, along with the DEA number, ensuring accurate identification of the pharmacy.
Input the worker’s social security number for identification purposes, followed by their claim number and full name.
Provide the worker’s mailing address and the date on which the pharmacy is billing for services rendered.
Complete the prescription details including date written, prescribing provider's name and number, prescription number, and date filled.
Indicate if it is a refill by entering the refill number. Specify days supply based on prescribed dosage.
List all ingredients used in compounding under 'Compound Itemization', ensuring each field is accurately filled out for reimbursement.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (238 Votes)
2010	4.3 Satisfied (208 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What does it mean when a prescription has to be compounded?

Compounded drugs are made by altering, mixing, or combining ingredients to create a medication tailored to an individual patient. Your doctor may prescribe a compounded medication when a standard, FDA-approved medication does not meet your health needs.

What are the different types of prescription forms?

Types of Prescriptions Explained Repeat Prescriptions. Repeat prescriptions is for medication you take for long term such as tablets. Variable Use Prescriptions. Acute Prescriptions. Dosette Boxes or Nomads. Controlled Drugs. Surgical Appliances and Devices. Electronic Prescribing/EPS. Nominated Chemist.

How to write a prescription for compounded medication?

Writing A Prescription For A Compounded Medication Patient identification (name, date of birth, address) Date. Drug allergies. Indicate prescription is to be compounded. Generic name of all active ingredients. Strength or Dose of medication (for example: %, milligram, grams)

Is compounded medication better?

Compounding Pharmacies vs. Regular Pharmacies Compounded drugs are drugs composed of two or more individual medications and create a vast number of new drug compounds. The result of this process is not FDA approved, and thus the safety and effectiveness of the drug cannot be guaranteed.

Does Walgreens fill compound prescriptions?

Medication compounding is available at select Walgreens locations. Find a location near you.

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Does insurance cover compounded prescriptions?

While compounded drugs are always supposed to contain FDA-approved ingredients, the formulations as prepared at compounding pharmacies arent reviewed by the FDA for purity, safety, or effectiveness. As a result, theres a chance that you may not be getting the drug that you think you are, stresses Dr.

What is a compounded prescription?

Compounding is the process of combining, mixing, or altering ingredients to create a medication tailored to the needs of a patient (FDA, 2017). 1. Compounding is most often practiced by a licensed pharmacist, a licensed physician, or a person under the supervision of a licensed pharmacist (FDA, 2017). 2.