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Worker Prescription Claim (form 3)

Use this form to request reimbursement of prescription receipts for expenses related to the injury on your accepted claim.   

Related forms:
Worker Supply and Services Claim (form 3a)
Worker Supply and Services Claim - Voc Rehab Expense Reimbursement (form 3B)

Publication Date: Apr 2017 File type: PDF (66 KB) Asset type: Form Form: 3