Fillable Pharmacy Billing Statement (Colorado DORA)

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Pharmacy Billing Statement (Colorado DORA)

On average this form takes 15 minutes to complete

The Pharmacy Billing Statement (Colorado DORA) form is 4 pages long and contains:

  • 0 signatures
  • 8 check-boxes
  • 58 other fields

Country of origin: US
File type: PDF

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Colorado Department of Regulatory Agencies (DORA) is responsible for professional licensing and consumer protection in Colorado USA.

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1
Instructions for Completing the
Pharmacy Billing Statement
Please read all pages
This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not
be able
to save the form onto your computer’s hard drive.
When you open the form, click in the “Insurance Carrier Name and
Address” box (field) and use the tab key to navigate to the next field.
Do not use the Enter
key; pressing the Enter key will only page down.
Each field has been limited. This means that you cannot continue to
type information into a field if it doesn’t fit into the space provided.
To fill in a check box, click inside the box with your mouse. “Insurance
Carrier Name and Address”, “Pharmacy Name and Address”, “Patient
Information” and “Employer Information” fields are surrounded by a
gray border. Type the information in the first field and tab to the next
to enter more information.
To clear or delete all the information you have typed onto the form,
click on the red “Clear Entire Form” button. To change the information
in one field, use the backspace or delete key.
Go to Form
2
“Clear Entire Form” button
Clears all information at once
“Gray Border” button
Enter information and tab to next field
3
“Check Box”
Click in Box
WC-M4 Rev 01/06
DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
PHARMACY BILLING STATEMENT
Insurance Carrier Name and Address:
Date:
Invoice Number:
Pharmacy Name and Address:
Tax ID Number:
Pharmacy NABP
Number:
Patient Information
Employer Information
Name of Patient:
Address:
Date of Injury:
Insurance Carrier Claim Number:
Employer Name:
Address:
Prescription Information
Rx#
RF#
Prescriber Name
NDC#
QTY
DS
Date
DAW
Total Price
Yes
No
Prescriber License #
Drug Name and Dosage
Rx#
RF#
Prescriber Name
NDC#
QTY
DS
Date
DAW
Total Price
Yes
No
Prescriber License #
Drug Name and Dosage
Rx#
RF#
Prescriber Name
NDC#
QTY
DS
Date
DAW
Total Price
Yes
No
Prescriber License #
Drug Name and Dosage
Rx#
RF#
Prescriber Name
NDC#
QTY
DS
Date
DAW
Total Price
Yes
No
Prescriber License #
Drug Name and Dosage
To the Pharmacy: Submit this statement directly to the insurance carrier.
C.R.S. Section 10-1-128(6) (a) states: “It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and
civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a
settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
A
gencies."
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Pharmacy Billing Statement (Colorado DORA)

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Completed 27 January 2021

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