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WSIB Medication Reimbursement Form

200 Front Street W estToronto ON M5V 3J1 WSIB MedicationReimbursement FormClaim most cases, your claim related medications can be billed on-line by your the pharmacist with your claim number and ask that your prescription be processed through the WSIB on-line for CompletionA. Worker InformationLast nameFirst nameInitials1. Please print clearly in black address2. Complete sections A, B, & C in full. CityProvince Postal CodeNew address?3. Send all original pharmacy receipts (or photocopies) with this form . Please write your claim number on each receipt. yes noDate of AccidentHome phoneW ork phoneBirth date (dd/mm/yyyy)For further information, please see the back of this Medication Information (found on prescription label) I am claiming repayment for the following Medication (s) I purchased: prescription No.(Rx) Total Total Amount Taken each time Howoften per dayDate DrugPharmacy NameName of Prescribing WSIB Use Only Cost of AmountDispensedDrug Name QuantityDrug IdentificationPhysician Telephone No.

Reimbursement Form In most cases, your claim related medications can be billed on-line by your pharmacist. Claim No. Provide the pharmacist with your claim number and ask that your prescription be processed through the WSIB on-line system. A. Worker Information Instructions for Completion Last name First name Initials 1. Please print clearly in ...

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