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When a PACIF member employee experiences a workplace injury, it's ideal for the supervisor to fill in and sign a print of this form and give it to the injured employee before the employee seeks medical treatment. If the injured employee is prescribed medication that is eligible for First-Fill coverage, they can have it filled right away without having to pay up front (out of pocket We encourage printing several copies of this form, having some handy in every supervisor's work area, and making sure all supervisors know to follow this procedure whenever possible.

This form is to be used for medications prescribed at an injured worker’s initial medical visit. If the employee is found to be entitled to workers’ compensation benefits and needs further medications, a Prescription ID Card will be provided to them.

Accurate handling of workers’ compensation claims can help keep claim costs down.


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