Remote Filling Verification - Click on 2 Different Errors
4122981
5/17/20XX
David Bontrager
Harold Green
Take one tablet by mouth twice daily at 8 AM and 12 Noon for
ADHD.
Dexedrine 5 mg Tablet
60
0
5/14/20XX
SKB
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00007-3519-20
Quantity: 60
Days Supply: 30
AWP Cost/Unit: $4.93
Total Drug Cost: $295.80
Dispensing Fee: $2.00
Total Billed: $297.80
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00007-3519-20
Quantity: 60
Days Supply: 30
AWP Cost/Unit: $4.93
Total Drug Cost: $295.80
Dispensing Fee: $2.00
Total Billed: $297.80
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number:
Dispensing Date: 5/17/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 5/17/20XX
Initials: RPh
Drug Manu: SKB
Rx Documentation
Dispensing Date: 5/17/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 5/17/20XX
Initials: RPh
Drug Manu: SKB
