Medication Reimbursement Form – WSIB in Ontario

The WSIB Medication Reimbursement Form is designed to facilitate the reimbursement process for medication expenses incurred by workers in Ontario related to a WSIB claim. This form requires specific information and adherence to detailed instructions to ensure proper processing and reimbursement. The Medication Reimbursement form is essential for ensuring that workers are reimbursed for medication expenses related to their WSIB claims, provided all instructions are carefully followed and the required documentation is submitted.

This guide will help you accurately complete the WSIB Medication Reimbursement Form to ensure your medication expenses related to a WSIB claim are reimbursed without delay.

Section A: Worker Information

• Last Name, First Name, Initials: Clearly print your last name, first name, and initials in black ink.
• Current Address: Provide your current address. If you have a new address, check the “New address?” box.
• City, Province, Postal Code: Enter the city, province, and postal code where you reside.
• Home Phone, Work Phone: Write down your home phone and work phone numbers.
• Birth Date: Enter your birth date in the format (dd/mm/yyyy).
• Date of Accident: Fill in the date of the accident that led to your WSIB claim.
• Claim Number: Ensure you provide your WSIB claim number. This is crucial for processing your reimbursement.

Section B: Medication Information

• Drug Name: List the name of the medication for which you are seeking reimbursement.
• Prescription Number (Rx): Enter the prescription number found on your medication label.
• Drug Identification Number (DIN): Provide the DIN from your prescription label.
• Name of Prescribing Physician: Write the full name of the doctor who prescribed the medication.
• Pharmacy Name: Indicate the name of the pharmacy where you purchased the medication.
• Pharmacy Telephone Number: Provide the telephone number of the pharmacy.
• Quantity: Enter the total amount of the medication provided (e.g., 250 ml, 50 tablets).
• Amount Taken Each Time: Specify the dosage taken each time (e.g., 15 ml, 2 tablets).
• How Often Per Day: Indicate how often you take the medication each day (e.g., 2 times/day).
• Dispensing Date: Enter the date the medication was dispensed in the format (dd-mm-yyyy).
• Total Cost of Drugs: Include the total cost of the medication, which should cover both the dispensing fee and the medication cost.
• Total Amount I Paid: Write the amount you paid to the pharmacy and for which you are requesting reimbursement.

Section C: Worker Declaration

• Signature: Sign your name to certify that the information provided is accurate and that the expenses were incurred for your WSIB claim. By signing, you agree not to seek reimbursement from other insurers for these expenses.
• Date: Date the form on the day you complete it.

Additional Instructions

• Receipts: Attach all original pharmacy receipts or photocopies to the form. Write your claim number on each receipt.
• Retain Copies: Keep the original receipts for 6 months as WSIB may ask for them later.
• Incomplete Forms: Ensure all sections are filled out completely. Incomplete forms, missing signatures, or missing receipts may delay your reimbursement.

Submission

• Local WSIB Office: Submit the completed Medication Reimbursement form and receipts directly to your local WSIB office.
• Additional Forms: More forms can be obtained from your pharmacist, local WSIB office, the WSIB website, or by calling 1-800-387-0750.

Contact Information

• WSIB Office Address: 200 Front Street West, Toronto, ON M5V 3J1
• Website: www.wsib.on.ca
• Toll-Free Number: 1-800-387-0750