Pharmacy Claim

Pharmacy Name _______________________________________________________

Address _______________________________________________________

_______________________________________________________

Reason for Submission ______________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

Date______________ erutangiS_______ ________________________________________________________

(1) only required for extemporaneous preparations. (F1) Claim also submitted to another paying agency Y N . (F2) Mask Rx at patients request Y . (F3) Adjudication Flag Y N .

Drug Plan and Extended Benefits Branch3475 Albert Street Regina, SK S4S 6X6

tsicamrahPredivorP htlaeHPatient Name and Health Services Number

Org ID Health Provider Identifier Pharmacist IDOrg ID

Day Month YearDispensing Date

Pharmacy Phone No.

Pharmacy No. Claim No.

P

Quantity D.I.N Unit Drug Cost Dispensing Fee Compounding Fee Discount% Total Rx Cost Patient PaidPrescription No. N/S

Days Supply Methadone MG per day Compound Name (1) F 1 F 2 F 3

- 1 -

. . ...

.

T3T2T1Mark-up %

Quantity D.I.N Unit Drug Cost Dispensing Fee Compounding Fee Discount% Total Rx Cost Patient PaidPrescription No. N/S

Days Supply Methadone MG per day Compound Name (1) F 1 F 2 F 3

- 2 -

. . ...

.

T3T2T1Mark-up %

Quantity D.I.N Unit Drug Cost Dispensing Fee Compounding Fee Discount% Total Rx Cost Patient PaidPrescription No. N/S

Days Supply Methadone MG per day Compound Name (1) F 1 F 2 F 3

- 3 -

. . ...

.

T3T2T1Mark-up %

Ministry of Health