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					Black Lung Medical Benefits:
Frequently Asked Questions about the Federal Black Lung Program




U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation
December 2004


The following material gives you basic information about your medical benefits, but it is neither intended to cover every
possible exception or special case, nor have the effect of law. Additionally, this information applies only if the Black Lung
Disability Trust Fund is responsible for your medical benefits. If a private party, such as your employer or its insurance
carrier, is responsible for your medical benefits, different procedures may apply. You may contact that private party directly
or the District Office which handles your claim with questions about your medical benefits. STOP HEALTH CARE FRAUD.
If you suspect any health care fraud, please call our toll-free number 1(800)347-2502.
Contents
Question           Subject                                                      Page #
1-3                Black Lung Benefits Identification Card                        2-3
4-5                State and Federal Black Lung Benefits                            3
6                  Social Security Black Lung Benefits                              3
7                  Covered Medical Services                                         4
8                  Covered Prescription Drugs                                       4
9-10               Approval for Certain Services                                    5
11                 Non-Covered Medical Services                                     5
12-16              Direct Billing by Medical Providers                              6
17                 Billing the Coal Company                                        7
18                 Reimbursing You for Medical Services                            7
19                 Reimbursing You for Prescription Drugs                          8
20                 Reimbursing You for Travel                                      9
21-24              Processing Reimbursement Requests                            9-10
25                 Change of Address                                              10
26-27              Keeping Copies for Your Records                                11
28                 Information Service                                            11


Samples
#       Subject                                                Corresponds to    Page #
1.      Black Lung Benefits Identification Card                       (Q #1)       2
2.      Medical Reimbursement Form, OWCP-915 (Doctor Visit)          (Q #18)      12
3.      Proof of Payment for Doctor Visit                            (Q #18)      13
4.      Medical Reimbursement Form, OWCP-915 (Prescription Drugs) (Q #19)         14
5.      Pharmacy Bill Receipt                                        (Q #19)      15
6.      Proof of Payment: Computerized Printout Pharmacy Receipt     (Q #19)      16
7.      Medical Travel Refund Request, OWCP-957                      (Q #20)      17
8. a.   Remittance Voucher (Front of Form)                           (Q #22)      18
8. b.   Remittance Voucher (Back of Form)                            (Q #22)      19


                                           i
Introduction                                      While this material gives you basic infor-
                                                  mation about your medical benefits, it is
Like all coal miners who qualify for the          neither intended to cover every possible
U.S. Department of Labor's Federal                exception or special case, nor have the
Black Lung Program, you are entitled to           effect of law. Additionally, this informa-
medical benefits to cover the reasonable          tion applies only if your medical benefits
cost of treatment, services or supplies for       are being paid by the U.S. Department of
your pneumoconiosis and disability                Labor. If a private party, such as your
(your black lung condition). Spouses,             employer or its insurance carrier, is
family members, and survivors of coal             responsible for your medical benefits,
miners are not entitled to medical bene-          different procedures may apply. You may
fits. You have the right to seek treatment        contact that private party directly or
from the medical provider (physicians,            write or call the U.S. Department of
pharmacies, hospitals, etc.) of your              Labor, Division of Coal Mine Workers'
choice. Most providers who are enrolled           Compensation (DCMWC) District
in the Federal Black Lung Program will            Office with which your claim is filed. For
bill the Federal Black Lung Program               further information about special cir-
directly for you. But if the provider is          cumstances or individual cases, please
not enrolled in the Federal Black Lung            write or call the District Office with
Program (or chooses not to bill directly),        which your claim is filed. If you are not
it will be necessary for you to pay for the       sure which District Office handles your
services yourself then file with the              claim, you may find out by calling toll-
Federal Black Lung Program on your                free, Mon.-Fri., 8:00 a.m.-8:00 p.m. (ET):
own for reimbursement of these out-of-            1-800-638-7072.
pocket payments.

The questions presented here are those
most often asked by Black Lung Program
beneficiaries about:
   The U.S. Department of Labor Black
   Lung Benefits Identification Card
   (medical treatment card);
   Medical benefits - covered and non-
   covered services; and,
   Reimbursement for medical care and
   associated travel.




                                              1
         What does the Black Lung                Sample 1. Black Lung Benefits
  1      Benefits Identification Card
         look like?
                                                           Identification Card

The U.S. Department of Labor Black
Lung Benefits Identification Card is
white with a Department of Labor logo,
and is imprinted with your name, an
effective date, and possibly an expiration
date. The red-and-white cards previ-
ously issued are obsolete and should be
destroyed. When medical providers bill
the Federal Black Lung Program or when
you submit reimbursement requests,
your nine-digit Social Security number is        1. This card is the property of the U.S. Government and its counterfeiting, alteration
your identification number. For privacy             or misuse is a violation of Section 499, Title 18, U.S. Code.
                                                 2. Carry this card with you at all times and show it to your doctor, clinic or hospital
reasons, your Social Security number                when you are in need of medical services for your lung condition.

does not appear on your card. However,           3. The U.S. Department of Labor will pay for medical treatment that is authorized
                                                    under the Black Lung Act. Call 1-800-638-7072 for specific details.

you will need to give your Social Security       4. All bills should be submitted to the DOL Black Lung Program, P.O. Box 8302,
                                                    London, KY 40742-8302.
number to your medical treatment                 5. If found, drop in mailbox. Postmaster, postage guaranteed. Return to: DOL Black
                                                    Lung Program, P.O. Box 8302, London KY 40742-8302.
providers so they can bill correctly.            6. When using the DOL OWCP bill payment website (http://owcp.dol.acs-inc.com/)
                                                    to request an authorization for medical services or to verify eligibility, your doctor
                                                    must use the following Card ID Number: 1234567830. Claimants can also use
                                                    this Card ID Number to access the DOL OWCP bill payment website.

                                                            MISUSE OF CARD IS PUNISHABLE BY LAW




         Is my personal information
  2      safe? What does my doctor
         need to know?

Your Social Security number and address          secure web site to get information about
are not printed on the card, and this is         your eligibility for benefits and about
information only you will know and will          bills they have filed. Your providers will
need to give to your medical providers.          probably want to photocopy both sides
There is a 10-digit number printed on            of the card for their records, because
the back of the card that is unique to           without the card ID number they will be
you. The purpose of this number is to            unable to access the secure part of our
allow the medical providers to access our        web site.


                                             2
          When do I use my U.S.                    Federal Black Lung Program. However,
  3       Department of Labor Black
          Lung Benefits Identification
                                                   bills or reimbursement requests must
                                                   first be submitted under the state pro-
          Card?                                    gram which awarded your benefits.

You should present your black lung card            If your medical providers' bills or your
whenever you seek treatment for your               own reimbursement requests are denied
lung condition. Showing a medical                  under your state award, send the bill or
provider your card will identify you as a          the reimbursement request and original
Federal Black Lung Program beneficiary,            receipts (as discussed in Question 18),
and will help the medical provider deter-          along with a copy of the denial letter, to:
mine the proper way to bill for services.          FEDERAL BLACK LUNG PROGRAM
                                                   P.O. BOX 8302
          I receive my black lung bene-            LONDON, KY 40742-8302
  4       fits through the U.S.
          Department of Labor around               If you have questions, please call the
          the middle of each month, but            DCMWC District Office that handles
I do not have a black lung card. What              your Federal Black Lung Program claim.
should I do?                                       If you do not have the address or phone
                                                   number of that office, you may get them
Write or call the DCMWC District Office            by calling toll-free, Mon.- Fri., 8:00 a.m.-
with which your claim is filed. If you             8:00 p.m. (ET): 1-800-638-7072.
are not sure which office handles your
claim, call toll-free, Mon.-Fri., 8:00 a.m.-                 I have been awarded black
8:00 p.m. (ET), and the operator can tell
you which District Office to contact:
                                                     6       lung benefits under both the
                                                             Federal Black Lung Program
1-800-638-7072.                                              and a State Workers' Compen-
                                                   sation Program. Should I have received
           I was awarded black lung ben-           a black lung card?
  5        efits by the Federal Black Lung
           Program. I also filed a claim           If you have been awarded benefits for
           with the state where I worked           your black lung condition under a State
as a coal miner and was awarded bene-              Workers' Compensation Program, you
fits for black lung. Am I still entitled to        will NOT receive an identification card
medical coverage under the Federal                 from the Federal Black Lung Program.
Black Lung Program?                                Expenses for the treatment of your black
                                                   lung condition that are not covered by
Expenses for the treatment of your black           the state program may be covered by the
lung condition that are not covered by             Federal Black Lung Program. (See
the state program may be covered by the            Question 5.)


                                               3
         What costs are covered under            The following items require special
  7      my Federal Black Lung
         Program medical benefits?
                                                 approval:
                                                    The purchase or rental of home
                                                    medical equipment such as oxygen
The cost of medical treatment services              systems exceeding $300 (requires
and associated travel for the treatment of          Certificate of Medical Necessity—See
your black lung condition is covered                Question 10—completed by pre-
under the Federal Black Lung Benefits               scribing physician);
Act. Payment for medical treatment serv-            Pulmonary rehabilitation (breathing
ices is subject to a maximum allowable              retraining) programs (requires
fee. There is no deductible or co-pay-              Certificate of Medical Necessity com-
ment. Payment for travel is limited to              pleted by prescribing physician);
reasonable costs.                                   Home health care visits for skilled
                                                    nursing (requires Certificate of
The following is a list of services that            Medical Necessity completed by pre-
MAY be covered when they are per-                   scribing physician); and,
formed for the treatment of your black              Overnight travel, related meals and
lung condition:                                     lodging, and/or mileage that exceeds
   Doctor's office calls, hospital visits,          150 miles round trip (requires special
   and consultations;                               approval from your DCMWC
   Inpatient and outpatient hospital                District Office).
   charges, including emergency room
   visits for ACUTE black lung related                     What prescription drugs are
   conditions, diagnostic laboratory
   testing and chest x-rays;
                                                   8       covered?

   Federal Black Lung Program
   APPROVED prescription drugs, both             Most drugs prescribed by your doctor
   brand name and generic;                       for the treatment of your black lung con-
   Ambulance services limited to trans-          dition will be covered (brand name or
   portation to the hospital for emer-           generic). However, there are some excep-
   gency ACUTE black lung related                tions. In order to be sure a drug is cov-
   care; and,                                    ered, you or your pharmacist may call
   Travel to the doctor, hospital, clinic,       toll-free, Mon.-Fri., 8:00 a.m.-8:00 p.m.
   or other medical facility for round           (ET): 1-800-638-7072. Your pharmacist
   trips of 150 miles or less.                   will also be able to learn at once if a drug
                                                 is covered if the bill is submitted by
                                                 Point-of-Sale technology.




                                             4
         Do I need prior approval for                    What costs are NOT covered
  9      certain services?                      11       by my Federal Black Lung
                                                         Program medical benefits?

Yes. Whether you or a medical provider          The following are among the costs NOT
does the billing, your doctor must com-         covered under the Federal Black Lung
plete the U.S. Department of Labor              Program:
Certificate of Medical Necessity, CM-893
(CMN), for oxygen and other durable                Treatment of medical problems NOT
medical equipment, pulmonary rehabili-             related to your black lung condition
tation, or skilled nursing care at home.           —for example, arthritis, diabetes,
                                                   and most heart conditions;
The doctor should send the completed               Medical treatment for your spouse or
form, with the results of the required             other family members;
medical tests attached, to the DCMWC               Dental or eye care, and X-rays other
District Office with which your claim is           than chest X-rays;
filed.                                             Nurse's aid (non-skilled nursing
                                                   care) services in the home;
CMNs for rental items must be re-                  Home health aides
approved periodically (a prescription for          Medicine that you can buy without a
oxygen concentrator, for example). All             doctor's prescription;
CMNs must have the DOCTOR'S ORIG-                  Medicine for problems other than
INAL SIGNATURE. Your treating physi-               your black lung condition;
cian's original signature is the ONLY              Personal services in the hospital, such
signature acceptable on the CMN. You,              as TV or telephone;
your physician, and the medical provider           Rental or purchase of an Intermittent
(if billing the Federal Black Lung                 Positive Pressure Breathing (IPPB)
Program for you) will be notified if               machine for home use;
the CMN has been approved or denied.               Travel to and from your drugstore;
                                                   Residence costs (room and board)
         Where can my doctor get a                 for nursing homes or skilled nursing
10       Certificate of Medical
         Necessity (CMN)?
                                                   facilities; and,
                                                   Home medical equipment not
                                                   authorized for coverage under the
Your doctor may call the Federal Black             Federal Black Lung Program.
Lung Program, toll-free, Mon.-Fri., 8:00
a.m.-8:00 p.m. (ET): 1-800-638-7072.
The form is also available for download-
ing and printing from our website, at
http://www.dol.gov/esa/regs/compli-
ance/owcp/cm-893.pdf.

                                            5
         What is the best way to get my                    Does the medical provider
12       medical bills paid?                     15        need special Department of
                                                           Labor billing forms?

WHENEVER POSSIBLE, have your doc-                NO. The doctor, clinic, laboratory,
tor, hospital, pharmacy and other med-           ambulance and nursing service can bill
ical providers bill the Federal Black Lung       using the standard OWCP-1500 form.
Program directly. If they are enrolled in
the Federal Black Lung Program as                The pharmacy can bill using the standard
providers, the Federal Black Lung                OWCP-1500 form or the Universal Phar-
Program will pay them directly. ALWAYS           macy Billing Form. They may also bill
show your Black Lung Benefits Identi-            directly at the Point-of-Sale for most drugs.
fication Card when seeking treatment.
                                                 The hospital can bill using the UB-92
         How can a medical provider              form for all inpatient charges and outpa-
13       get enrollment and billing
         information from the Federal
                                                 tient charges for emergency room,
                                                 chemotherapy and ambulatory surgical
         Black Lung Program?                     care. The OWCP-1500 form should be
                                                 used for other outpatient charges.
Medical providers not already participat-
ing in the Federal Black Lung Program                      What if the medical provider
may apply for enrollment at any time.
Those having questions about enrollment
                                                 16        wants to bill Medicare,
                                                           UMWA, or other insurance
or billing may call the Federal Black Lung                 carriers instead of the Black
Program, toll-free, Mon.-Fri., 8:00 a.m.-                  Lung Program?
8:00 p.m. (ET): 1-800-638-7072. They
may also apply online at http://owcp.dol.         Other insurance carriers should NOT be
acs-inc.com/portal/providerEnrollment.do.        billed first for treatment of your black
                                                 lung condition, because Federal Black
         Where should medical                    Lung Program medical benefits represent
14       providers send Black Lung
         related bills?
                                                 primary coverage for beneficiaries
                                                 (unless there is a black lung award under
                                                 a state program. See Question 5).
Answer: ALL Federal Black Lung                   Medicare and many other insurance car-
Program medical treatment bills should           riers have a "workers' compensation
be sent to the following address:                exclusion clause." This means that they
FEDERAL BLACK LUNG PROGRAM                       will not pay for treatment of occupation-
P.O. BOX 8302                                    al disease, like black lung disease, if a
LONDON, KY 40742-8302                            patient has medical coverage under a
                                                 workers' compensation program or the
                                                 Federal Black Lung Program.

                                             6
         The U.S. Department of Labor            receipts" are NOT acceptable, when used
17       has notified me that the coal
         company has agreed to pay for
                                                 in any of the boxes on the form.

         medical treatment for my                Send the completed Medical
black lung. How is this handled?                 Reimbursement Form with your item-
                                                 ized paid statements or detailed receipts,
You will need to ask the coal company or         securely attached, to:
its insurance carrier how and where both         FEDERAL BLACK LUNG PROGRAM
you and medical providers who might              P.O. BOX 8302
bill for you should submit medical               LONDON, KY 40742-8302
claims. Usually, a medical benefit identi-
fication card is NOT issued by the coal          Your detailed receipts or itemized state-
company. If you need help, you may               ments MUST include the following
write or telephone the DCMWC District            information:
Office that handles your claim.                      Your full name;
                                                     Name and address of the medical
         What if I have to pay the med-              provider;
18       ical provider? How do I get
         reimbursed by the Federal
                                                     Signature of the medical provider;
                                                     Description of medical service per-
         Black Lung Program?                         formed;
                                                     Date of service;
Present your Black Lung Benefits                     Primary diagnosis or condition treated;
Identification Card to the medical                   Charge for each individual service;
provider whenever you seek treatment                 and,
for your lung condition. A medical                   Total amount you paid.
provider may bill directly, if already
enrolled in the Federal Black Lung               Receipts and statements must be marked
Program.                                         "patient paid" or "paid by patient" to
                                                 show specifically who paid the charges.
If you must pay for the medical services
out-of-pocket then you may request               "Paid" or "paid in full" are NOT acceptable.
reimbursement by completing the U.S.
Department of Labor Medical                      A copy of the front and back of your
Reimbursement Form, OWCP-915, as                 canceled check may serve as proof of
shown in Sample 2. Up to eight visits or         payment ONLY when accompanied by
services can be listed on this form.             an itemized statement or copy of the
However, each line used MUST be filled           doctor's ledger record. (See Sample 3.)
in COMPLETELY. Therefore, statements
such as "see attached" or "see attached



                                             7
          How do I get reimbursed for                11-digit National Drug Code (NDC)
19        prescription drugs?                        number for the prescribed medica-
                                                     tion;
                                                     Charge actually paid for each drug
To obtain reimbursement, fill out a                  less any discount (for example, sen-
Medical Reimbursement Form, OWCP-                    ior citizen, coupon, etc.); a
915, as shown in Sample 4. Up to nine                A statement, marked "patient paid"
individual prescription drugs may be                 or "paid by patient," showing specifi-
listed on this form. However, each line              cally who paid the charges. "Paid" or
used MUST be filled in COMPLETELY.                   "paid in full" are NOT acceptable.
Therefore, statements such as "see
attached" or "see attached receipts" are          (See Sample 5.)
NOT acceptable when used in any of the
boxes on the form.                                NOTE: If you send an itemized comput-
                                                  erized printout, it MUST include all of
Send the completed Medical                        the information already listed, as well as
Reimbursement Form, along with the                the PHARMACIST'S ORIGINAL SIG-
original pharmacy receipts, securely              NATURE.
attached, to:
FEDERAL BLACK LUNG PROGRAM                        (See Sample 6.)
P.O. BOX 8302
LONDON, KY 40742-8302                             Your own itemized listing or cash regis-
                                                  ter receipt is NOT considered proof of
These are acceptable receipts: a pharmacy         payment.
bag or sticker, a computerized printout,
or an itemized listing on the pharmacy's          A copy of the front and back of your
letterhead. These receipts MUST include:          canceled check may serve as proof of
    Your full name, address, and social           payment, ONLY when accompanied by
     security number;                             an itemized statement or pharmacist's
     Name of the prescribing doctor;              ledger record.
     Name and address of the pharmacy;
     Prescription number;                         If you need help getting or completing
    Amount prescribed - mg/ml or cc               forms for the reimbursement of pre-
     and total ml or cc per bottle for liq-       scription drugs, please call toll-free,
     uid medication, and/or mg per tablet         Mon.-Fri., 8:00 a.m.-8:00 p.m. (ET): 1-
     and total number of tablets per pre-         800-638-7072.
     scription;
     Date purchased;
     Name of each drug;



                                              8
         Can I be reimbursed for the                      How much time will my reim-
20       cost of travel to get medical
         treatment related to my black
                                                 21       bursement requests take to be
                                                          processed?
         lung?
                                                 Reimbursement requests which are sub-
Mileage costs for most travel to obtain          mitted correctly will be processed by the
medical treatment for your lung condi-           Federal Black Lung Program within 30
tion may be reimbursed. To get reim-             days.
bursement, you must complete a Medical
Travel Refund Request, OWCP-957, as                       Will I be notified if the reim-
shown in Sample 7. You may submit up
to three trips on each form. However,
                                                 22       bursement requests I send in
                                                          are going to be paid?
you MUST have the MEDICAL
PROVIDER, or an authorized represen-             You will be notified by mail if your reim-
tative, complete and SIGN block "H" for          bursement requests will be paid or
each visit.                                      denied, through a form called a
Mail the completed Medical Travel                Remittance Voucher, as shown in
Refund Request to:                               Samples 8.a. and 8.b. This statement will
FEDERAL BLACK LUNG PROGRAM                       contain the following information:
P.O. BOX 8302                                       The date of service;
LONDON, KY 40742-8302                               The amount of your reimbursement
                                                    request;
NOTE: Overnight travel, related meals               The amount you will be paid;
and lodging, and/or mileage that exceeds            A Remittance Voucher number at the
150 miles round trip requires special               top of the form. (This number will
prior approval from the DCMWC                       also appear on your check, if you
District Office. If you are not sure which          receive a payment, so you can match
office to contact, call the toll-free num-          payments with your reimbursement
ber, Mon.-Fri., 8:00 a.m.-8:00 p.m. (ET):           requests.); and,
1-800-638-7072.                                     A "Message Code" which will explain
Travel to a pharmacy to pick up pre-                why you were not paid for any por-
scriptions is NOT covered.                          tion of the reimbursement request.
                                                    You will NOT receive a Remittance
Sample 7. Medical Travel Refund                     Voucher if your medical provider
Request, OWCP-957                                   bills the Federal Black Lung Program
                                                    directly.




                                             9
         What will happen if I have not                     Will a check come with the
23       submitted my reimbursement
         request forms or receipts cor-
                                                  24        Remittance Voucher (RV)?

         rectly? Will I still receive a                      No, the check is always mailed
         Remittance Voucher?                      separately. Checks are issued by the U.S.
                                                  Treasury Department. The RV is sent
Any reimbursement request forms and               from the Federal Black Lung Program
receipts that need correction or addi-            office where your reimbursement
tional information will be returned to            requests are processed. The RV will usu-
you along with a letter explaining what is        ally arrive shortly after your check.
wrong or missing. It is very important            Please remember to allow enough time
that you correct and mail back these              (10 to 14 days) for both the check and
forms and receipts as soon as possible.           the RV to arrive before making inquiries.
You cannot be paid by the Federal Black
Lung Program until you submit all                 If you have questions about your RV, if
forms and receipts properly. All correct-         you fail to receive either a check or an
ed reimbursement forms and receipts               RV, or if your payment is incorrect and
should be mailed to:                              requires an adjustment, you may call
FEDERAL BLACK LUNG PROGRAM                        toll-free, Mon.-Fri., 8:00 a.m.-8:00 p.m.
P.O. BOX 8302                                     (ET): 1-800-638-7072.
LONDON, KY 40742-8302
                                                            Whom should I notify if my
If you need help correcting reimburse-
ment requests which have been returned,
                                                  25        mailing address changes?

you may call toll-free, Mon.-Fri., 8:00
a.m.-8:00 p.m. (ET): 1-800-638-7072.              Any changes in your mailing address
                                                  should be reported to the DCMWC
                                                  District Office with which your claim is
                                                  filed. If you are not sure which office
                                                  handles your claim, call toll free, Mon.-
                                                  Fri., 8:00 a.m.-8:00 p.m. (ET), and the
                                                  operator will tell you whom to contact:
                                                  1-800-638-7072.




                                             10
         Should I keep copies of the
26       bills that I send to the Federal
         Black Lung Program?

YES, if possible. Keeping a copy will give
you a record of the reimbursement
requests and receipts you have submitted.

         Will I be notified when pay-
27       ments are made directly to my
         doctor, pharmacist, or other
         provider?

You will only receive Remittance
Vouchers for reimbursements paid
directly to you. However, once a year
you will be mailed a record of all pay-
ments made on your behalf. You should
review this record carefully.

          Whom do I call if I have ques-
28        tions about my medical bills;
          if I need reimbursement
          forms for treatment, prescrip-
tions or travel; or, if my Black Lung
Benefits Identification Card has been
lost or destroyed?

You may call the Federal Black Lung
Program's toll-free number, Mon.-Fri.,
8:00 a.m.-8:00 p.m. (ET): 1-800-638-7072.




                                             11
Sample 2. Medical Reimbursement Form, OWCP-915 (Doctor Visit)




                             12
Sample 3. Proof of Payment for Doctor Visit




   Your full name
   Your address
   Your Social Security Number
   Name and address of medical provider
   Signature of medical provider
   Diagnosis or Condition Treated
   Date of Service
   Description of Service Performed
   Charges for each type of service
   Total amount you paid
   A statement showing specifically who paid the charges (PATIENT PAID or
   PAID BY PATIENT). "PAID" or "PAID IN FULL" are not acceptable.

If you need help getting or completing this form, please call toll-free, Mon.- Fri.,
8:00 a.m.-8:00 p.m. (ET): 1-800-638-7072.

                                             13
Sample 4. Medical Reimbursement Form, OWCP-915
          (Prescription Drugs)




                            14
Sample 5. Pharmacy Bill Receipt



                                   Prescription Drugs
                                   Receipts can be the pharmacy bag or
                                   sticker, a computerized printout, or an
                                   itemized listing on the pharmacy's letter-
                                   head. These receipts must include:
                                       Your full name, address, and social
                                       security number
                                       Name of the prescribing doctor
                                       Name and address of the pharmacy
                                       Prescription number
                                       Amount prescribed-mg/ml or cc and
                                       total ml or cc per bottle for liquid
                                       medication, and/or mg per tablet
                                       and total number of tablets per pre-
                                       scription
                                       Date purchased
                                       Name of each drug
                                       11-digit National Drug Code (NDC)
                                       number for the prescribed medica-
                                       tion
                                       Charge actually paid for each drug
                                       less any discount (e.g., senior citizen
                                       or coupon)
                                       A statement showing specifically who
                                       paid the charges (PATIENT PAID or
                                       PAID BY PATIENT). "PAID" or
                                       "PAID IN FULL" are not acceptable.




                              15
Sample 6. Proof of Payment: Computerized Printout
          Pharmacy Receipt




                              16
Sample 7. Medical Travel Refund Request, OWCP-957




                             17
Sample 8.a. Remittance Voucher (Front of Form)




                              18
Sample 8.b. Remittance Advice (Back of Form)




                              19
                                            www.dol.gov

Employment Standards Administration   U.S. Department of Labor   Office of Workers’ Compensation Programs

				
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