HTML Preview Pharmacy Invoice Template Example page number 1.
BI-401
01/15
Pharmacy Invoice
BrickStreet Insurance
P.O. Box 3151
Charleston, WV 25332
1. Claimant’s Name (Last, First and Middle)
2. Claimant’s Address (Street or P.O. Box, City, State, Zip)
3. Employer’s Business Name
4. Employer’s Mailing Address
5. Claimant’s Social Security Number
6. Date of Injury
7. Claim Number
8. Name of Pharmacy
9. NABP No.
10. Check here if payment is to be made to
claimant
PRESCRIPTION DETAIL
11. Date Written
12. Date Filled
13. Prescribing Physician
14. Prescribing Physician’s DEA No.
15. Prescription No.
16. Billing Unit (please check one)
Each ML GM
17. National Drug Code (11 digits)
18. Drug Name
19. Generic Yes No
20. Drug Quantity
21. Est. Days Supply
22. Refill Yes No
23. Amount Paid
24. Brand Name Justification (DAW Code from Pharmacist)
25. Pharmacy Phone Number (include area code)
26. Claimant’s Signature Date
27. Pharmacist’s Signature Date
11A. Date Written
12A. Date Filled
13A. Prescribing Physician
14A. Prescribing Physician’s DEA No.
15A. Prescription No.
16A. Billing Unit (please check one)
Each ML GM
17A. National Drug Code (11 digits)
18A. Drug Name
19A. Generic Yes No
20A. Drug Quantity
21A. Est. Days Supply
22A. Refill Yes No
23A. Amount Paid
24A. Brand Name Justification (DAW Code from Pharmacist)
25A. Pharmacy Phone Number (include area code)
26A. Claimant’s Signature Date
27A. Pharmacist’s Signature Date
As provided by statues, this is to certify that the medication(s) was provided as outlined above and that no other or
additional charge for such medication(s) has been or will be made against any person, firm or corporation.
28. Remarks
29. Provider Name and Address
MUST HAVE RECEIPTS ATTACHED
ALL PHARMACY INVOICES SHOULD BE SUBMITTED WITHIN 30 DAYS FROM THE DATE OF SERVICE
BRICKSTREET INSURANCE DOES NOT REIMBURSE INSURANCE CO-PAYMENTS
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