Washington > Workers Comp > Crime Victims Compensation
Statement For Crime Victim Mental Health Services F800-025-000 - Washington
| Statement For Crime Victim Mental Health Services Form. This is a Washington form and can be used in Crime Victims Compensation Workers Comp . |
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Department of Labor and Industries Crime Victims Compensation Program PO Box 44520 Olympia WA 98504-4520 STATEMENT FOR CRIME VICTIM MENTAL HEALTH SERVICES DO NOT WRITE IN SPACE Claimant's full name Last Address City Claim Number VFirst Middle Social Security Number (for ID only) Date of Injury Date of Birth State ZIP BE SURE TO INCLUDE YOUR PROVIDER NUMBER AND YOUR PATIENT'S CLAIM NUMBER OR YOUR BILL MAY BE DENIED. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (use ICD-9-CM, DSM III or DSM IV). Designate left or right when applicable. 1. 2. 3. 4. 5. ENTER ONLY ONE ITEM PER LINE Date of Service POS Procedure Code Mod Code Describe services provided If mental health patient is not victim, give name and the relationship to victim. Charges $ Unit To Date of Service 1. 2. 3. 4. 5. 6. 7. The submission of this bill certifies that the material furnished, service(s) provided, expense incurred, or any other item of indebtedness as charged in the foregoing bill is a true and correct charge against the state of Washington; that the claim is just and due. Signature: Bill date: Amount Paid by Primary Insurance $ Provider of Service Name Group, Clinic, Center or Facility Name Address City Federal Tax ID Number Name of Primary Insurance Company Individual Provider No./NPI Total Charge Group Provider No./NPI Phone Number Your Patient's Account Number State ZIP+4 EIN SSN PLEASE ATTACH A COPY OF THE EXPLANATION OF BENEFITS OR YOUR BILL MAY BE DENIED F800-025-000 statement for crime victim mental health services 08-09 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING CRIME VICTIMS MENTAL HEALTH SERVICES BILLING FORM Crime Victims is a secondary insurer. Submit bills to public or private insurance first. You must attach Primary EOB to your bill. 1. 2. 3. 4. 5. 6. 7. 8. A. B. C. D. E. F. G. H. I. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. CLAIM NUMBER: Enter claimant's crime victim claim number. CLAIMANT'S NAME: Enter claimant's last name, first name and middle name. SOCIAL SECURITY NUMBER: Enter claimant's social security number. DATE OF INJURY: The date of injury/illness positively identifies each claim. ADDRESS: Enter claimant's current address. DATE OF BIRTH: Enter claimant's date of birth. DIAGNOSIS: Enter ICD-9-CM, DSM III or DSM IV code number and the narrative diagnosis for all conditions treated. Designate left or right side of body when applicable. ITEMIZATION OF SERVICES AND CHARGES: DATE OF SERVICE: Enter the month, day and year of service. (e.g., January 04, 2002 = 010402). When billing for more than one date of service, only consecutive days may be billed on the same line. If dates of service are not consecutive, list each date on a separate line. PLACE OF SERVICE: Pl ace of Service codes are printed below . Enter appropriate code in space provided. PROCEDURE CODE: Identify the procedure (CPT®/HCPCS/Local Code) performed or item provided. Enter only one code per line. CODE MODIFIER: A modifier provides the means by which the provider can indicate a performed service or procedure has been altered by some specific circumstance, but has not changed in the definition or code. DESCRIBE SERVICES PROVIDED: Enter brief description of services furnished. RELATIONSHIP TO VICTIM: Enter patient's name and relationship to claimant. CHARGES: Enter your usual and customary fee for the procedure billed on this line. Do NOT bill negative charges UNIT: Enter the total number of times a procedure is provided per line. TOTAL CHARGES: Total of all charges. PROVIDER OF SERVICE NAME: Enter name of provider providing service. PROVIDER NUMBER: Enter the provider of service Department of labor and Industries provider account number. NPI: Enter the provider's National Provider Identifier (optional for Crime Victims Compensation Program) PROVIDER'S ADDRESS AND PHONE NUMBER: Enter provider's billing address as recorded with the Department of Labor and Industries. TOTAL CHARGE: Total of all charges. SIGNATURE: Signature may be that of the provider or the person preparing the bill. Regardless of who signs the bill, the provider submitting the bill is responsible for its accuracy. If the bill is prepared by computer, the signature may be left blank. BILL DATE: The date your billing was prepared. FEDERAL TAX I.D. NUMBER: Required. If the provider account number is incorrect this information helps identify the correct provider. PATIENT'S ACCOUNT NO.: The number you use to identify your patient's account. This is for your convenience only. AMOUNT PAID BY PRIMARY INSURANCE: The Crime Victims Compensation Program is a secondary insurer, public and private insurance must be billed first. Enter amount paid by public or private insurance. NAME OF PRIMARY INSURANCE: Enter the name of the public or private insurance making payments on behalf of the claimant. Place of Service (POS) 05 06 07 08 11 21 22 23 26 31 32 33 Indian Health Service Free-standing Facility Indian Health Services Provider-based Facility Tribal 638 Free-standing Facility Tribal 638 Provider-based Facility Office Inpatient Hospital Outpatient Hospital Emergency Room Hospital Military Treatment Facility Skilled Nursing Facility Nursing Facility Custodial Care Facility 35 50 51 52 53 54 55 56 61 62 71 72 99 (none) Adult Living Care Facility Federally Qualified Health Center Inpatient Psychiatric Facility Psychiatric Facility Partial Hospitalization Community Mental Health Center Immediate Care Facility/Mental Retarded Residential Substance Abuse Treatment Center Psychiatric Residential Treatment Center Comprehensive Inpatient Rehabilitation Facility Comprehensive Outpatient Rehabilitation Facility State or Local Public Health Clinic Rural Health Clinic Other Unlisted Facility (Place of Service Code not supplied) CPT* codes and descriptions only are copyright 2001 American Medical Association Remember to attach Primary EOB to your bill. F800-025-000 statement for crime victim mental health service inst 08-09 American LegalNet, Inc. www.FormsWorkFlow.com
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