Wsib medication reimbursement form 2025

1. Click ‘Get Form’ to open the WSIB medication reimbursement form in the editor.
2. Begin by filling out Section A, Worker Information. Provide your last name, first name, current address, city, province, postal code, work phone, and home phone. Ensure all details are accurate.
3. In Section B, Medication Information, clearly print your claim number on each original pharmacy receipt. List the medications you are claiming repayment for by entering the prescription number (Rx), drug name, Drug Identification Number (DIN), pharmacy name, and prescribing physician's name along with their telephone number.
4. For each medication listed, specify the quantity dispensed, amount taken each time, frequency per day, total cost of drugs including dispensing fees, and the date the drug was dispensed.
5. Complete Section C by signing and dating the form to certify that all information is true and complete. Remember to retain all original receipts as they must be submitted with your form.

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