Statement For Miscellaneous Services F245 072 000 245
User Manual: 245-072
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STATEMENT FOR MISCELLANEOUS SERVICES Mail completed forms to: Department of Labor and Industries PO Box 44269 Olympia WA 98504-4269 Type of Service: Instructions on next page Dental Service Glasses Home Health / Nursing Home Transportation Vocational/Retraining Other: Worker Information (Please print) Claim No. Name (Last, First, Middle Initial) Date of injury Home address (not PO Box) Apt # City State ZIP Medical Equipment/ Prosthetics-Orthotics Social Security No. (for ID only) Phone no. Provider Information (Please print) L&I provider number/NPI Provider name Your Patient Account Number Address Federal Tax ID/Employer ID Number City State Name of referring physician or other source ZIP Referring provider number/NPI Billing Information To Date of Service POS Proc Code Mod Mod Referral ID Is this bill to reimburse the injured worker? Yes (Receipt and signature required) For inpatient services: For glasses, is the old prescription available? Yes No From Date of Service Phone no. No Date admitted:__________ Date discharged: ____________ Diagnosis Describe procedures, medical services or supplies furnished. Dental tooth # Home Nursing No. of Hourly/ hrs/day Day rate Charges Units 1 2 3 4 5 6 7 8 9 10 Total Charge $ Worker Signature: These expenses are related to my workers’ compensation claim and I have not been reimbursed for them. I understand it is a crime to submit information I know is false. Provider Signature: I certify that the information in the bill is true and correct. I have not been reimbursed for any part of this bill. Signature (Required for worker reimbursement) Signature F245-072-000 Statement for Miscellaneous Services 01-2014 Date Date RESET Instructions for completing the Statement for Miscellaneous Services: Type of Service: Check the appropriate box for the type of service for which you are billing. If your type of service is not listed, check the “Other” box and list the type of service you provided. Worker Information: Claim number Name Date of injury Home address Social Security Number Phone number Provider Information: L&I provider number/NPI Provider name Provider address Your Patient Account Number Federal Tax ID Phone number Name of referring physician or other source Referring provider number/NPI Referral ID Bill Information: Is this bill to reimburse the injured worker? For glasses, is the old prescription available? For inpatient services Give the worker’s claim number. Write the worker’s legal name in the last, first, middle initial format. Date of injury. Give the most current physical address of the worker. Write the worker’s Social Security Number. Used to verify claim number only. Write the worker’s phone number. Give the provider’s L&I provider number or provider’s NPI. Write the provider’s name as registered with L&I. Write the provider’s physical address. Write the number you use to identify your patient’s account. This field is optional and not used by L&I. Write the Federal Tax ID (EIN) for the billing provider. This must match the EIN on file with the agency. Give the phone number where the agency can call if there any questions about your bill. Write the name of the referring physician or other source for the services provided. Write the L&I provider number or NPI of the referring provider Write the referral ID number. Check the appropriate box. If this bill is to reimburse a worker, receipts are required. Send copies of your receipts. Receipts must be itemized and legible. No credit card slips. Check the appropriate box. Write date of admission and the date of discharge in the mm/dd/yy format. Use one line for each service provided. Complete each applicable field. From date of service Starting date of service. To date of service Ending date of service. POS Place of service. See the list below for the appropriate two-digit code. Proc Code Procedure code. Mod Modifier code if applicable. Diagnosis Diagnosis code. Enter the primary diagnosis code for each service. Description Give a brief description of services provided. Dental tooth number Tooth number dental services were provided for. Home nursing Give the number of hours you are billing for. Give your hourly or daily rate for your services. Charges Enter the charge for each service provided. Units Enter the number of units for service. Place of Service Codes 03. School 04. Homeless shelter 22. Outpatient hospital 23. Emergency room - hospital 53. Community mental health ctr 54. Intermediate care facility/mentally retarded 05. Indian Health Service free-standing facility 24. Ambulatory surgical center 55. Residential substance abuse trmt center 06. Indian Health Service provider-based facility 25. Birthing center 56. Psychiatric residential trmt ctr 07. Tribal 638 free-standing facility 26. Military treatment facility 57. Non-residential substance abuse treatment center 08. Tribal 638 provider-based facility 09. Correctional facility 31. Skilled nursing facility 32. Nursing facility 11. Office 12. Patient's home 33. Custodial care facility 34. Hospice 60. Mass immunization center 61. Comprehensive inpatient rehabilitation facility 62. Comprehensive outpatient 65. End stage renal disease treatment facility 14. Group home 15. Mobile unit 16. Temporary lodging 41. Ambulance - land 42. Ambulance - air or water 49. Independent clinic rehabilitation facility 71. State or local public health clinic 72. Rural health clinic 81. Independent laboratory 17. Walk-in retail health center 20. Urgent care facility 21. Inpatient hospital 50. Federally qualified hlth ctr 51. Inpatient psychiatric facility 52. Psychiatric facility partial hospitalization 99. Other unlisted facility F245-072-000 Statement for Miscellaneous Services 01-2014
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