Supplemental Agreement 3rd Party Pharmacy Page 4
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5Instructions for completing the form
Enter the name of the third party pharmacy biller.
1.
Enter the L&I assigned dispensing pharmacy provider number associated with the third party
2.
pharmacy biller.
a. If you do not have a current L&I provider number for the pharmacy, you will need to
complete and return an L&I Provider Application and a W-9 form along with the Third
Party Pharmacy Provider Supplemental Agreement.
Enter the billing address where payments should be mailed.
3.
Enter the Tax Payer Identification Number (EIN or SSN).
4.
Enter the contact person’s name
5.
Enter the contact person’s phone number where we may call to ask questions regarding your
6.
bills or account, if necessary.
Print the name and title of person authorizing this agreement.
7.
Must be signed and dated for agreement to be processed.
8.
Enter the name of the dispensing pharmacy.
9.
Enter the dispensing pharmacy’s NCPDP number [formerly known as the NABP number].
10.
Enter the dispensing pharmacy’s National Provider Identifier (NPI) number.
11.
Enter the dispensing pharmacy’s Tax Payer Identification Number (EIN or SSN).
12.
Enter the dispensing pharmacy’s address [physical location of the business].
13.
Enter the dispensing pharmacy’s contact person’s name
14.
Enter the dispensing pharmacy’s contact person’s phone number where we may call to ask
15.
questions regarding pharmacy transactions, if necessary.
Print the name and title of the person authorizing the third party pharmacy biller to submit
16.
bills on the dispensing pharmacy’s behalf.
Must be signed and dated for agreement to be processed.
17.
F249-021-000 supplemental agreement third party pharmacy provider 03-2007
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