North Dakota > Workers Comp
Request For Payment For Home Health Care SFN 54303 - North Dakota
| Request For Payment For Home Health Care Form. This is a North Dakota form and can be used in Workers Comp . |
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REQUEST FOR PAYMENT FOR HOME HEALT CARE TH CLAIMS DIVISION S SFN 5430 (04/2010) 03 1600 EA AST CENTURY A AVENUE, SUITE 1 E PO BOX 558 85 BISMARC ND 58506-558 CK 85 Telephon 1-800-777-503 ne 33 Toll Free Fa 1-888-786-869 ax 95 TTY ( (hearing impaired 1-800-366-688 d) 88 Fraud a Safety Hotlin 1-800-243-333 and ne 31 www.Wo orkforceSafety.co om T This form mu be filled out complete with as much detail a possible. Please print or type usin black or ust o ely m as t ng b blue ink. If th form is no filled out completely, it will be retu his ot c urned to you, and your pa , ayment will b delayed. be Inju ured Worker's Name Claim N Number PAYME ENT INFORMA ATION Ple ease enter the rate, numb of hours, and total fo r each servic that has b ber ce been provide ed. 552 SKILL LED NURSING DA ATE Medic & Personal cal Car including re Regis stered Nurses (RN) and Licensed Practical Nurses (LPN) ) RATE HRS TOTAL L 572 5 CREDENTIALED CA ARE Medical & Personal Care includ ding Certified Nurses Aides (CNA) A 582 NON NCREDENTI IALED CARE E Medical & Pe ersonal Care includin family ng members, fri iends or other hired pe ersonnel that have no e certificat tion RATE HRS TOTAL 589 HOMEMAKIN NG SERVICES Mu be in conjun ust nction wi medical/pers ith sonal care. Including non npe ersonal care hir to red do cooking, cleaning o o running erran or nds RA ATE HRS TO OTAL RATE OTHER RATE HR RS TOTAL HRS TOTA AL TO OTAL PAYME ENT REQUES ST INFO ORMATION OF PERSON PROVIDING SERVICE O N G Name Address FEIN or Socia Security Num al mber* City Fraud War rning for Filing Fals Claims se ming benefits or co ompensation from WSI who files a fals claim, or makes a false statement , or fails to notify W as to the receipt of income or W se s WSI Any person claim an increase in in ncome from employ yment, in connectio with any claim or application for w on o workers' compensa ation benefits will fo orfeit any future be enefits and may be guilty of a felony which is punishable by imprison nment, substantial fines, or both. Th hese criminal pena alties are applicabl to all persons dealing with the le Fund, including injured workers, em i mployers, medical providers, and attor p rneys. To report an ins stance of fraud, con ntact the ND Fraud and Safety Hotline at 1-800-777-503 e 33. Ce ertification/Licen Number nse Zip Phone Number e Sta ate Sig gnature Dat te C C40b American LegalNet, Inc. www.FormsWorkFlow.com * In com mpliance with the Federal Privacy Act of 1974, disclosur of the social secu F t re urity number on thiis form is mandator pursuant to N.D. ry .C.C. 65-05-02. Th social security he numbe is used for identif er fication and verifica ation purposes. Fail lure to provide this information may re esult in a delay in p processing your req quest. HOME HEALTH CARE GUIDELINES Services for home health care must be approved by WSI prior to care being provided. Under the Home Health Care Fee Schedule, there are certain services that can only be provided by a Home Health Agency. These services include: · Physical Therapy · Occupational Therapy · Speech Language Pathology · Clinic Social Worker's services · Home IV services Payment for home health services provided by private individuals treating the injured worker will be paid to the approved individual providing the service. These services would need prior approval and include: · Homemaking services (including cooking, cleaning and errands). These services must be approved in conjunction with medical/personal care. · Medical care provided by non-credentialed individuals · Medical care provided by credentialed (CNA) individuals · Skilled nursing care by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) WSI can approve care based on a per visit rate or an hourly rate, depending on the level of care required. If the care requires services being provided from 1-3 hours, payment would be on a per visit rate. If the care required will exceed the 3-hour limit, then care on an hourly base may be approved within the WSI Fee Schedule amount. The Home Health Care Fee Schedule can be found at www.WorkforceSafety.com/library under the Medical Providers section. This shows the level of care and allowable rates. American LegalNet, Inc. www.FormsWorkFlow.com
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