Statement For Miscellaneous Services F245 072 000 245
User Manual: 245-072
Open the PDF directly: View PDF 
.
Page Count: 2
Mail completed forms to:
Department of Labor and Industries
PO Box 44269
Olympia WA 98504-4269
STATEMENT FOR
MISCELLANEOUS SERVICES
Instructions on next page
Type of Service:
Dental Service
Glasses
Home Health / Nursing Home
Medical Equipment/
Prosthetics-Orthotics
Transportation
Vocational/Retraining
Other:
Worker Information (Please print)
Claim No.
Name (Last, First, Middle Initial)
Date of injury
Home address (not PO Box) Apt #
Social Security No. (for ID only)
City State ZIP
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 ZIP
Phone no.
Name of referring physician or other source
Referring provider number/NPI
Referral ID
Billing Information
Is this bill to reimburse the injured worker?
Yes (Receipt and signature required) No
For glasses, is the old prescription available?
Yes No
For inpatient services:
Date admitted:__________ Date discharged: ____________
From
Date of
Service
To
Date of
Service
POS
Proc Code
Mod
Mod
Diagnosis
Describe procedures,
medical services or
supplies furnished.
Dental
tooth #
Home Nursing
Charges
Units
No. of
hrs/day
Hourly/
Day rate
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) Date Signature Date
1
2
3
4
5
6
7
8
9
10
F245-072-000 Statement for Miscellaneous Services 01-2014
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
Give the worker’s claim number.
Name
Write the worker’s legal name in the last, first, middle initial format.
Date of injury
Date of injury.
Home address
Give the most current physical address of the worker.
Social Security Number
Write the worker’s Social Security Number. Used to verify claim number only.
Phone number
Write the worker’s phone number.
Provider Information:
L&I provider number/NPI
Give the provider’s L&I provider number or provider’s NPI.
Provider name
Write the provider’s name as registered with L&I.
Provider address
Write the provider’s physical address.
Your Patient Account Number
Write the number you use to identify your patient’s account. This field is optional and not used by L&I.
Federal Tax ID
Write the Federal Tax ID (EIN) for the billing provider. This must match the EIN on file with the
agency.
Phone number
Give the phone number where the agency can call if there any questions about your bill.
Name of referring physician or
other source
Write the name of the referring physician or other source for the services provided.
Referring provider number/NPI
Write the L&I provider number or NPI of the referring provider
Referral ID
Write the referral ID number.
Bill Information:
Is this bill to reimburse the
injured worker?
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.
For glasses, is the old
prescription available?
Check the appropriate box.
For inpatient services
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
22. Outpatient hospital
53. Community mental health ctr
04. Homeless shelter
23. Emergency room - hospital
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
31. Skilled nursing facility
60. Mass immunization center
09. Correctional facility
32. Nursing facility
61. Comprehensive inpatient rehabilitation
facility
11. Office
33. Custodial care facility
62. Comprehensive outpatient
12. Patient's home
34. Hospice
65. End stage renal disease treatment facility
14. Group home
41. Ambulance - land
71. State or local public health clinic
15. Mobile unit
42. Ambulance - air or water
72. Rural health clinic
16. Temporary lodging
49. Independent clinic rehabilitation facility
81. Independent laboratory
17. Walk-in retail health center
50. Federally qualified hlth ctr
99. Other unlisted facility
20. Urgent care facility
51. Inpatient psychiatric facility
21. Inpatient hospital
52. Psychiatric facility partial hospitalization
F245-072-000 Statement for Miscellaneous Services 01-2014
