WORKERS' COMPENSATION Rx PROGRAM Letter of Intent for First

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WORKERS’ COMPENSATION Rx PROGRAM Letter of Intent for First Choice Rx Prescription The top portion of this form must be completed before giving it to your pharmacist. Injured Employee: _______________________________ Social Security #____________________ Date of Injury: ___________________ Employee Phone: __________________________________ Employee Date of Birth: _____________ Description of Injury: ____________________________ Employer Name: ________________________________________________ Employer Representative: ________________________ Phone: ____________________________ To Employer: Please complete and give this form to the Injured Employee. The Employee may take this completed form to any pharmacy to expedite the processing of their approved workers’ compensation prescriptions. For your convenience, some of the major pharmacy chains are listed below. To Pharmacist: This employer has selected MSC–Medical Services Company to administer its workers’ compensation prescription drug program through the RESTAT network. For immediate authorization and online billing information, contact MSC at: 1 800 848 1989 ext 1414. Please state that you have received a Letter of Intent and give the MSC patient care coordinator the MSC control number located in the bottom right hand corner of this form. CHAINS PARTICIPATING IN THE PHARMACY NETWORK A & P PHARMACY FAGAN PHARMACY KERR DRUG STORE SAVE MART PHARMACY ALBERTSONS FARMER JACK PHCY. KING SOOPERS SCHNUCK’S PHARMACY ARBOR DRUGS FAY’S DRUG STORE KINNEY DRUGS SHOP ‘N SAVE DRUGS ARROW PRESC. CTR. FINAST PHARMACY KROGER DRUG SHOPKO PHARMACY AURORA FOOD TOWN PHCY. LONG’S DRUG STORE SMITH’S FOOD & DRUG BARTELL DRUG FRED MEYER MANAGED PHCY. CARE SNYDER BI LO PHARMACY FRED’S PHARMACY MARC’S PHARMACY STOP & SHOP PHCY. BI MART DRUG FRY’S FOOD & DRUG MAXI/BROOKS PHCY. SUPER D DRUGS BIG BEAR FURR’S PHARMACY MEDICAP PHARMACY TARGET PHARMACY BROOKS PHARMACY GENOVESE DRUG STORE MEDIC DISC. DRUG TEXAS DRUG WRHS. BROOKSHIRE GIANT EAGLE PHCY. MEDICINE SHOPPE TEXAS ONCOLOGY BRUNO’S GIANT FOOD INC. MEDISTAT PHARMACY THRIFT DRUG CARRS GIANT PHARMACY MEIJER PHARMACY THRIFTY/PAYLESS DRUG CITY MARKET GRAND UNION PHCY. OSCO DRUG THRIFTY WHITE DRUG COSTCO HANNAFORD DRUG PAMIDA PHARMACY TIMES PHARMACY CUB PHARMACY HARCO DRUG PATHMARK PHARMACY TOM THUMB/PAGE DRUG CVS PHARMACY HARVEST FOODS PHCY. PERRY DRUG STORE TOPS PHARMACY D & W PHARMACY H E B PHARMACY PRICE CHOPPER UNITED MANAGED CARE DILLON PHARMACY HI SCHOOL PHARMACY PRICE COSTCO PHCY. UNITED PHARMACY DISCOUNT DRUG MART HORIZON PUBLIX PHARMACY VON’S PHARMACY DOMINICK’S HY VEE PHARMACY RANDALL’S FOOD MKTS. WAL MART PHARMACY DRUG EMPORIUM INTEGRATED PHARMACY RITE AID PHARMACY WALGREENS DRUG FAIR K & B PHARMACY RITZMAN PHARMACY WEIS PHARMACY DUANE READE K MART SACK N’ SAVE WELBY SUPER DRUG EDGEHILL PHARMACY KARE DRUGS SAFEWAY PHARMACY WINN DIXIE PHARMACY EDWARDS PHARMACY KASH & KARRY PHCY. SAV ON DRUGS MSC Control Number: 00710.

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