Form Dfs-F2-Dwc-1 - First Report Of Injury Or Illness Template Page 5
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9FICURMA
Workers’ Compensation Prescription Information
Employer:
Please fill out employee information below and provide employee with this document to take to any pharmacy with prescriptions.
Employee Name:
Group#:
10602857
Member ID (SSN):
Date of Injury:
Processor:
myMatrixx
Bin#:
014211
Day supply is limited to 14 days for a new injury.
myMatrixx Help Desk: (877) 804-4900
Employee:
FICURMA has partnered with myMatrixx to make filling workers’ compensation prescriptions easy.
This document serves as a temporary prescription card. A permanent prescription card specific to your injury will be forwarded
directly to you within the next 3 to 5 business days.
Please take this letter and your prescription(s) to a pharmacy near you. myMatrixx has a network of over 64,000 pharmacies
nationwide. If you need assistance locating a network pharmacy near you, please call myMatrixx toll free at (877) 804-4900.
IF YOU ARE DENIED MEDICATION(S) AT THE PHARMACY PLEASE CALL (877) 804-4900
_
Pharmacist:
Please obtain above information from the injured employee if not already filled in by employer to process prescriptions for the
workers’ compensation injury only.
For questions or rejections please call (877) 804-4900. Please do not send patient home or have patient pay for medication(s)
before calling myMatrixx for assistance.
NOTE: Certain medications are pre-approved for this patient; these medications will process without an authorization. All
others will require prior approval.
FOR ALL REJECTIONS OR QUESTIONS CALL: (877) 804-4900
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