Form 0806A "Wsib Medication Reimbursement Form" - Ontario, Canada

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Download Form 0806A "Wsib Medication Reimbursement Form" - Ontario, Canada

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200 Front Street West
WSIB Medication
Toronto ON M5V 3J1
Reimbursement Form
Claim No.
In most cases, your claim related medications can be billed on-line by your pharmacist.
Provide the pharmacist with your claim number and ask that your prescription be processed through the WSIB on-line system.
Instructions for Completion
A. Worker Information
Last name
First name
Initials
1. Please print clearly in black ink.
2. Complete sections A, B, & C in full.
Current address
City
Province
Postal Code
New address?
3. Send all original pharmacy receipts
yes
no
(or photocopies) with this form.
Date of Accident
Home phone
Work phone
Birth date (dd/mm/yyyy)
Please write your claim number on
each receipt.
For further information, please see
the back of this form.
B. Medication Information
(found on prescription label)
I am claiming repayment for the following medication(s) I purchased:
Prescription No.(Rx)
Amount
How
Date Drug
Total
Total
WSIB Use
Name of Prescribing
Pharmacy Name
Taken
often
Cost of
Amount
Dispensed
Drug Name
Quantity
Drug Identification
Physician
each
per
Telephone No.
*
* *
Only
Drugs
I Paid
Number (DIN)
dd
mm
yyyy
time
day
Pharmacy Name
Rx No.
Telephone:
DIN
Rx No.
Pharmacy Name
Telephone:
DIN
Rx No.
Pharmacy Name
Telephone:
DIN
Rx No.
Pharmacy Name
Telephone:
DIN
Rx No.
Pharmacy Name
Telephone:
DIN
Rx No.
Pharmacy Name
Telephone:
DIN
*
* *
Total cost including dispensing fee.
Amount you paid the pharmacy and want WSIB to reimburse you.
C. Worker Declaration
I hereby certify, that to the best of my knowledge, the information provided on this form is true, accurate and complete and that all the expenses listed were for drugs dispensed to me for my use and for my WSIB
claim. I agree to retain all original receipts or photocopies and provide them to the WSIB. I will not request reimbursement from any other insurers/organizations for expenses paid for by the WSIB. I also authorize the
release of any information to the WSIB relating to the expenses listed on this form.
Type your name and upload, or print and sign before returning to WSIB
Signature
Date
DRF
0806A (03/18)
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print
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200 Front Street West
WSIB Medication
Toronto ON M5V 3J1
Reimbursement Form
Claim No.
In most cases, your claim related medications can be billed on-line by your pharmacist.
Provide the pharmacist with your claim number and ask that your prescription be processed through the WSIB on-line system.
Instructions for Completion
A. Worker Information
Last name
First name
Initials
1. Please print clearly in black ink.
2. Complete sections A, B, & C in full.
Current address
City
Province
Postal Code
New address?
3. Send all original pharmacy receipts
yes
no
(or photocopies) with this form.
Date of Accident
Home phone
Work phone
Birth date (dd/mm/yyyy)
Please write your claim number on
each receipt.
For further information, please see
the back of this form.
B. Medication Information
(found on prescription label)
I am claiming repayment for the following medication(s) I purchased:
Prescription No.(Rx)
Amount
How
Date Drug
Total
Total
WSIB Use
Name of Prescribing
Pharmacy Name
Taken
often
Cost of
Amount
Dispensed
Drug Name
Quantity
Drug Identification
Physician
each
per
Telephone No.
*
* *
Only
Drugs
I Paid
Number (DIN)
dd
mm
yyyy
time
day
Pharmacy Name
Rx No.
Telephone:
DIN
Rx No.
Pharmacy Name
Telephone:
DIN
Rx No.
Pharmacy Name
Telephone:
DIN
Rx No.
Pharmacy Name
Telephone:
DIN
Rx No.
Pharmacy Name
Telephone:
DIN
Rx No.
Pharmacy Name
Telephone:
DIN
*
* *
Total cost including dispensing fee.
Amount you paid the pharmacy and want WSIB to reimburse you.
C. Worker Declaration
I hereby certify, that to the best of my knowledge, the information provided on this form is true, accurate and complete and that all the expenses listed were for drugs dispensed to me for my use and for my WSIB
claim. I agree to retain all original receipts or photocopies and provide them to the WSIB. I will not request reimbursement from any other insurers/organizations for expenses paid for by the WSIB. I also authorize the
release of any information to the WSIB relating to the expenses listed on this form.
Type your name and upload, or print and sign before returning to WSIB
Signature
Date
DRF
0806A (03/18)
print
reset
save
Instructions to Worker
Incomplete information, not signing and dating the form, or not providing original receipts may result in the form being returned to you and /or delay
the processing of your payment.
1. Your WSIB claim number must be included on this form.
2. Original medication receipts, photocopies or faxes (not pharmacy printouts) must be sent with this form. We encourage you to send in your receipts
or photocopies immediately.
3. WSIB will not return original receipts or photocopies. For photocopies please retain your original receipts for 6 months as you may be asked to submit them.
4. WSIB will not accept requests for co-payments for medication paid by the Ministry of Health or any other insurer.
5. Quantity of the drug dispensed refers to the total amount provided to you (e.g. 250 ml. or 50 tablets, etc.).
6. Amount taken each time is the dosage of the drug dispensed each time you take it (e.g. 15 ml. or 2 tablets, etc.).
7. How often per day is the number of times you take the drug (e.g. 2 times /day, one at suppertime, etc,).
8. Dispensing Date is the date the drug was provided to you (dd-mm-yyyy).
9. For Total Cost of Drugs, enter the total cost of the medication you need. This should include both the dispensing fee and the cost of the medication itself.
10. Total amount I Paid is the amount you actually paid to the pharmacist and are asking the WSIB to reimburse you for.
You may submit your form directly to your local WSIB office.
Additional forms are available from your Pharmacist, your local WSIB office, our website at www.wsib.on.ca or by calling us Toll Free at 1-800-387-0750.
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