Ohio > Workers Comp > Medical Providers
Service Invoice BWC-1124 - Ohio
| Service Invoice Form. This is a Ohio form and can be used in Medical Providers Workers Comp . |
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Service Invoice 1. Billtype(Pleasecheckone) Instructions ·Completeallapplicableportionsofthisfeebillandmailtotheappropriateparty,eitherBWCortheMCO. ·Mailalldocumentationtothelocalcustomerserviceoffice. ·Forinstructionsonhowtocompletethisinvoice,refertotheBWC'sBilling and Reimbursement Manual. (K) ( N) (P) (R) (V) Dental Nursing Practitioner Vocationalrehabilitation Othervendor 2.Claimnumber 3.InjuredworkerSocialSecuritynumber 5.Injuredworker'sname(last,firstandmiddleinitial) 6.Injuredworker'saddress(streetorP.O.Box,city,stateandZIPcode) 7.Referringphysicianprovidernumber 8.Referringphysicianname 9.Priorauthorizationnumber(ifapplicable) 10.Patientaccountnumber(15max) 11.Providernumber 12.Providername 13.Checkhereiftotalpaymentistobemadetoinjuredworker 14.Grouppayeenumber(ifdifferentfromprovidernumber) 15. Service date 17. 18. 16. 19. Procedure Place Diagnostic code Modification of code code service CPT/HCPCS ICD-9-CM 20. Descriptionofservice 21. Charges 22. 23. Units of Tooth service No. Iherebycertifytheinformationcontainedonthisformistrueandcorrecttothebestofmyknowledgeandbelief. 26.Total charge 24. 27.Remarks Providersignature 25. Date 28.Payeename,address,city,state,ZIPcodeandtelephonenumber (print,stamportype) Icertifytheinformationonthisformistrueandcorrect.Iunderstandthatanypersonwhoknowinglymakesafalsestatement,misrepresentation, concealmentoffactoranyotheractoffraudtoobtainpaymentasprovidedbyBWC,orwhoknowinglyacceptspaymenttowhichthatpersonisnot entitledissubjecttofelonycriminalprosecutionandmay,underappropriatecriminalprovisions,bepunishedbyafineorimprisonmentorboth. BWC-1124(Rev.9/21/2010) C-19 American LegalNet, Inc. www.FormsWorkFlow.com
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