Form 25p - North Carolina Industrial Commission - Itemized Statement Of Charges For Drugs
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1North Carolina Industrial Commission
IC File #
I
S
C
D
TEMIZED
TATEMENT OF
HARGES FOR
RUGS
Emp. Code #
Carrier Code #
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act
Employer FEIN
(
)
Employee’s Name
Employer's Name
Telephone Number
Address
Employer’s Address
City
State
Zip
City
State
Zip
Insurance Carrier
(
)
(
)
Home Telephone
Work Telephone
Carrier's Address
City
State
Zip
(
)
(
)
M
F
/
/
Social Security Number
Sex
Date of Birth
Carrier's Telephone Number
Fax Number
NAME OF DRUG &
DATE
DRUG STORE
CITY
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
EMPLOYEE:
Mail your bill in duplicate promptly to
employer and/or insurance carrier
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.
NCIC - M
B
S
EDICAL
ILLING
ECTION
F
25P
ORM
4337 M
S
C
AIL
ERVICE
ENTER
2/01
R
, NC 27699-4337
ALEIGH
1
P
1
AGE
OF
M
T
: (919) 807-2500
AIN
ELEPHONE
F
25P
ORM
H
: (800) 688- 8349
ELPLINE
W
:
://
.
.
.
/
EBSITE
HTTP
WWW
IC
NC
GOV
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