Medical & Pharmaceutical Items Reimbursement Form

Medical & Pharmaceutical Items Reimbursement Forms (NT)

  • Please note that in emailing this form to Gallagher Bassett from your designated email account, you declare that you have paid for this service and that the details of this form are true and correct and are related to your compensable disability. If insufficient evidence is received, we will not pay until relevant information is provided.
  • Item DescriptionFor What Injury (eg elbow)Type - Prescription or Over the Counter (please select one)Name of medical expert who prescribed or recommended item 
  • Drop files here or
    Please note that in sending this form to Gallagher Bassett you declare that you have paid for the item/s listed and that the details of this form are true and correct and are related to your compensable disability. If insufficient evidence is received, we will not pay until relevant information is provided.
  • If you wish to receive payment electronically please provide your account details below: