Authorization Number : 855-1126
Agency Series No. : MSAD - 55
Status : Active
Agency Web Link :
Agency : BWC
Confidential Description : The medical providers’ tax identification numbers, names of injured workers, claim numbers, addresses, telephone numbers, medical information, type of prescriptions, and payment amounts.
Division : BWCMSAD
Vital Description :
Section : BWCMSAD
Record Title : C 17 – Outpatient Medication Reimbursement Request Form
Revision : 0
Record Description : The C 17 – Outpatient Medication Reimbursement Request Form is completed by the Pharmacy that dispensed the medication and is submitted by the injured worker to the Pharmacy Benefits Manager contracted by BWC. Injured workers only use this form for reimbursement of outpatient medication. The C 17 is scanned into the injured worker’s claim file and is to be retained for the retention period of the claim file.