Prescription Re-Pricing

Fields labeled in green are required

Adjuster Information

First Name: Last Name:

E-Mail Address:

Phone: - - Extension:

Requested Action:
Set up pharmacuetical program
Do not set up for future prescriptions
Previously set up pharmaceutical program

Claimant Information

First Name: Last Name:

Claim #:

Employer:

Date of Injury:

Date of Birth:

Address:

City: State: Zip Code:

Phone: - -

All medications listed on the bill are approved?
Yes No One-Time Only

The physician listed on the bill is approved?
Yes No One-Time Only

Additional Information:

Fields labeled in green are required