Injured employee prescription fill form
1 page - 153.3 KB
Indicate that this is a new workers' comp injury; do not process under an existing injury. process using the temporary id # provided by healthesystems.
Document in text mode:
Injured Employee Prescription Fill Form Instructions for: Employer or Claim Handler Please complete this form before providing to Injured Employee. Asterisk (*) denotes a required field. *Last Name, First Name: *Social Security Number: *Date of Injury: *Date of Birth: *Employer Name: Claim Number if Known: Instructions for: Injured Employee To fill your prescriptions for a workers' compensation injury, follow these easy steps: 1. Present this form to your pharmacist. 2. Locate a participating pharmacy closest to you. For assistance use the following tools: Call: 1-877-528-9497 l Visit: www.healthesystems.com/pharmacysearch A sample listing of pharmacies is provided at the bottom of this form Instructions for: Pharmacists Your pharmacy has contracted to participate in the Healthesystems Pharmacy Network. First Fill Script: To dispense the injured employee’s first fill for their workers' compensation prescription: Call the Healthesystems Customer Service Center: 1.877.528.9497 Indicate t...
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