This form is used for the reimbursement of items or drugs purchased by an injured worker.
Pharmacies my use this from to direct bill WorkSafeNB for approved personal items purchased by the client for the compensable injury.
Out of Province pharmacies may also use this form for direct billing of approved drugs. They do not have access to e-pay
This guide can help you comply with Section 50.2 of the General Regulation 91-191.
NOTE: Not for use when a safety monitor is part of the fall protection system on a work site.