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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the Worker Information section. Enter your social security number, claim number, full name, mailing address, and employer's name clearly.
- Next, move to the Pharmacy Information section. Provide the pharmacy's name and physical address, along with their L&I provider number or NPI.
- In the Prescription Information section, complete all fields as required by entering details such as the date written, prescribing provider's name and number, prescription number, and drug information including quantity and total cost.
- Finally, ensure you sign in the Injured Worker Signature section to certify that all information is accurate. Don’t forget to attach your receipts for reimbursement.
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