Pharmacies use this one-page statement to list prescriptions dispensed for a WorkSafeNB claim, either to bill WorkSafeNB directly or to support reimbursement when the claimant has already paid. Each line records the date of purchase, prescription number (DIN or PIN), drug name and strength, quantity and charge, followed by a subtotal, HST/GST and total.
The pharmacy, as supplier, fills in the prescription lines, its name and address and its payee code, along with the claimant, doctor and employer details. The claimant signs to acknowledge receipt of the drugs.
Download the current version from the source each time; forms change without notice.
Form 33 – Claimant Prescription Information
Formulaire 33 – Détails de l'ordonnance
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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The claimant. Their signature acknowledges receipt of the drugs and agreement to accept financial responsibility for any part of the account not accepted by WorkSafeNB. The pharmacy completes the prescription lines and supplier details, including its payee code.
Form 33 allows for it: the total can be marked as already paid by the claimant instead of being submitted by the pharmacy for payment. The form lists each purchase date, DIN or PIN, drug, strength, quantity and charge, and WorkSafeNB decides which part of the account it accepts.