Statement For Pharmacy Services (Crime Victims) {F800-058-000} | Pdf Fpdf Doc Docx | Washington

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Statement For Pharmacy Services (Crime Victims) {F800-058-000} | Pdf Fpdf Doc Docx | Washington

Last updated: 10/24/2024

Statement For Pharmacy Services (Crime Victims) {F800-058-000}

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Description

F800-058-000 - CRIME VICTIMS STATEMENT FOR PHARMACY SERVICES. This form is used to request reimbursement for pharmacy services related to a crime victim's claim filed with the Washington State Department of Labor and Industries (L&I). It allows pharmacies or claimants to seek reimbursement for prescription costs, insurance co-payment reimbursements, or payments made by the claimant. The form requires detailed information about the prescription, the prescribing provider, and the pharmacy, including the drug's national code, prescription number, cost, and dates. It also certifies the accuracy of the prescription information submitted for reimbursement. www.FormsWorkflow.com

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