North Carolina Industrial Commission
IC File #
ITEMIZED STATEMENT OF CHARGES FOR DRUGS
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act
Emp. Code # Carrier Code # Employer FEIN
(
Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address
)
Telephone Number City State Zip
(
) M F
( /
)
City State Fax Number Zip
Home Telephone Social Security Number Sex
Work Telephone
/
(
)
(
)
Date of Birth
Carrier's Telephone Number
DATE
DRUG STORE
CITY
NAME OF DRUG & PRESCRIPTION NO.
PHYSICIAN
AMOUNT
TOTAL
$
This is to certify that the drugs listed above were related to my workers' compensation injury.
(Receipts must be furnished for carrier's file)
Employee signature Carrier's approval Reimburse employee Yes no Reimburse drug store Yes no EMPLOYER OR CARRIER/ADMINISTRATOR: DRUGS MAY BE REIMBURSED DIRECTLY TO THE EMPLOYEE OR DRUG STORE. IT IS NOT NECESSARY TO SUBMIT BILLS TO THE COMMISSION FOR APPROVAL. PAY AND RETAIN COPY IN CARRIER'S FILE. EMPLOYEE: Mail your bill in duplicate promptly to employer and/or insurance carrier
FORM 25P 2/01 PAGE 1 OF 1
FORM 25P
NCIC - MEDICAL BILLING SECTION 4337 MAIL SERVICE CENTER RALEIGH, NC 27699-4337 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688- 8349 WEBSITE: HTTP://WWW.IC.NC.GOV/