Washington > Workers Comp > Claims
Interpretive Services Appointment Record F245-056-000 - Washington
| Interpretive Services Appointment Record Form. This is a Washington form and can be used in Claims Workers Comp . |
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Department of Labor and Industries INTERPRETIVE SERVICES APPOINTMENT RECORD Date of Injury (last, first, middle initial) Claim Number Use for workers' compensation or crime victim claims. Send original to insurer. Interpreter: Keep photocopy for your records. Claimant's phone # Claimant's name APPOINTMENT INFORMATION Name of scheduled health care / vocational provider Street address of health care / vocational provider Type of appointment: Please check below May be completed by Interpreter or Language Agency Appointment date City Start time State Language requested Doctor PT or OT Hospital PCE Other Vocational Pharmacy Diagnostic IME Telephone number ( ) Comments INTERPRETER INFORMATION Name of interpreter (last, first, middle initial) Completed by Interpreter Interpreter's Provider Number Agency's Provider Number City City City State State State Language agency's name, if applicable Interpreter's travel starting address Appointment address Return or next appointment location Mileage to appointment Mileage to next appointment Interpreter's Total Mileage Important: Submit Mileage documentation printout from a software mileage program and name of software program Scheduled start time Completion time Group service information If this was a group service, please indicate number of total persons served in the group and divide service time and mileage accordingly. Indicate total number of persons served in the group: Total billable time Minutes: Interpreter's arrival time Date By signing this document, I certify that I have provided the interpretive services indicated above. Signature INTERPRETER SERVICES VERIFICATION Diagnosis code (ICD code): Comments: Completed by Health Care of Vocational Provider or their designee. Do not sign unless information above has been completed. Send original to insurer. Interpreter keep photocopy for your records. Name of person verifying services (print) Signature of person verifying services Title Date CLAIM INFORMATION (submit original to insurer) Do not staple documentation to bill forms. Send documentation separately from bills to: State Fund Crime Victim Compensation Self-insurer Department of Labor and Industries PO Box 44291 Olympia, WA 98504-4291 1-800-848-0811 360-902-6500 FAX 360-902-4567 Department of Labor and Industries PO Box 44520 Olympia, WA 98504-4520 1-800-762-3716 360-902-5377 FAX 360-902-5333 Varies Call 360-902-6901 to obtain Insurer's phone number and address OR See Self-insurer list at: http://www.lni.wa.gov/ClaimsIns/Providers/billing/billSIEmp/default.asp Index: TSAR F245-056-000 Interpretive Services Record 12-2012 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing INTERPRETIVE SERVICES APPOINTMENT RECORD Submit original to the insurer. Do not staple documentation to bill forms. Use the proper address on bottom of other side to send documentation. Some Guidelines to complete form: Claim Number: This is our tracking device. Please ensure the Claim Number of the client is accurate. Name of scheduled provider: This may be a health care or vocational provider with whom client is scheduled. Comments: Any special request information or other instructions. Interpreter Provider Number: Enter the L&I state fund or Crime Victims assigned provider number for the interpreter. Language Agency Provider number: Enter the L&I state fund or Crime Victims assigned provider number for the language agency. Mileage to appointment: Calculate the miles from the origins of the trip to the destination. Mileage documentation is required. Documentation must be a printout from a software mileage program and name of software program Mileage from appointment: This is the return mileage. Mileage must be split between ALL clients of a group and between clients if there are multiple appointments in one day. If services are delivered in multiple locations for same client, mileage is payable but not the travel time between locations. Mileage documentation is required. Documentation must be a printout from a software mileage program and name of software program Total billable time: Enter the total billable time (excluding travel time between appointments). Bill from the arrival time or scheduled start time-whichever is LATEST. Interpreter's TRAVEL time is NOT payable. Group Services: If more than one person was served, please enter the information. Group service time must be divided between ALL clients in the group. After calculating the total mileage and billable time, divide by the total number of clients served in that appointment. Comments: Please enter any additional information about the services or appointment as needed. IMPORTANT: Health care or vocational provider or designated staff must sign to verify services. IMPORTANT: Mileage documentation is required. Documentation must be a printout from a software mileage program and name of software program F245-056-000 Interpretive Services Record 12-2012 American LegalNet, Inc. www.FormsWorkFlow.com
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