Workers' Compensation

Thank you for your interest in Workers’ Compensation Prescriptions.

Please take the time to fill out this request form below. We will contact your Doctor’s office. We always offer FREE shipping direct to your door with any prescription.

No out of pocket costs*

Fast, convenient service

Most employer plans accepted

Name *

First

Last

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Sex

Male
Female

Social Security #

Date of Birth

Date of Injury

Claim Number

I don't have all the information. Please call me anyway.

Medical Information

Physician's Name

First

Last

Physician's Phone

Insurance or Employer Information

WC Carrier or Employer Name

WC Carrier or Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

WC Carrier or Employer Phone

If WC carrier information is not available, please complete with Employer information

*On approved claims

Name