Washington > Workers Comp > Crime Victims Compensation
Statement For Home Nursing Services (Crime Victims) F800-070-000 - Washington
| Statement For Home Nursing Services (Crime Victims) Form. This is a Washington form and can be used in Crime Victims Compensation Workers Comp . |
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NO STAPLES IN BAR CODE AREA STATEMENT FOR HOME NURSING SERVICES Department of Labor and Industries Crime Victims Compensation Program PO Box 44520 Olympia WA 98504-4520 DO NOT WRITE IN SPACE Claimant's name in full Last Address City Date of Injury First Middle Claim Number Social Security Number (for ID only) State Name of referring physician or other source ZIP Reimburse Claimant Yes No Referring physician provider number / NPI REFUND CERTIFICATION I hereby certify under penalty of perjury that this is a true and correct claim for the necessary expenses incurred by me, that the claim is just and due and that no payment has been received by me on account thereof. CLAIMANT'S SIGNATURE: CHARGES $ ยข DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (use ICD-9-CM) Designate left or right when applicable 1. 2. 3. 4. 5. FROM DATE OF SERVICE For glasses, advise if old Rx was available Yes No Give hospitalization date for inpatient services Admitted Discharged * POS PROC CODE MOD CODE Describe procedures, medical services or supplies furnished. Attach lab reports, X-ray findings and any special services Dental Tooth Number Home Nursing No. of Hourly/ hrs/day Day rate GLASSES OLD RX NEW RX OD OS OD OS Unit TO DATE OF SERVICE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Submission of this bill certifies the material furnished, service provided, expense incurred or 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; that no part of the same has been paid. Signature: Bill date: Remarks: * Place of Service (POS) codes on back F800-070-000 statement for home nursing services 08-09 Provider or Supplier name Address City Federal tax ID number Provider Number NPI Taxonomy Total Charge State ZIP+4 Phone Number Your Patient's Account Number EIN SSN American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING HOME NURSING SERVICES STATEMENT 1. CLAIMANT'S NAME: Claimant's full name, last name first. 2. CLAIM NUMBER: For the claimant receiving services. Crime Victim claim numbers are six digits preceded by a "V", or five digits preceded by a "VA, VB, VC, VH, VJ, VK, VL, VM, VN, or VS". Send bills for Crime Victims claims to: Department of Labor and Industries PO Box 44520 Olympia WA 98504-4520 Department bill forms are furnished at no charge to the vendor and can be obtained by calling the local department office or the main office in Olympia. ADDRESS: The claimant's most current address. SOCIAL SECURITY NUMBER: Record claimant's social security number. It is helpful when the claim number is wrong and the claimant's name is common. REIMBURSE CLAIMANT: Place an "X" in the applicable box. If payment should be made to the claimant, indicate the amount paid. DATE OF INJURY: This is important and must be included. One person may have several claims so it is vital the proper claim be identified and charged for services provided. The date of injury positively identifies each claim. 7. NAME OF REFERRING PHYSICIAN: The name of the physician who has referred the claimant to you, the provider, for services. 8. REFERRING PHYSICIAN PROVIDER NUMBER: The Department of Labor and Industries provider account number or NPI of the referring physician. The number may be obtained from the referring physician. 9. DIAGNOSIS: Not applicable. 10. FOR GLASSES: Not applicable. 11. SERVICES RELATED TO HOSPITALIZATION: If claimant was hospitalized, record the date admitted and the date discharged. 12. REFUND CERTIFICATION - FOR CLAIMANT REIMBURSEMENT: Signature of the claimant who received the care. 13. ITEMIZATION OF SERVICES AND CHARGES: A. DATE(s) OF SERVICE: Record the date for each service provided. For consecutive dates of service, (i.e., home nursing care, attendant care) record both beginning (from-date-of-service column) and ending (to-date-of-service column) dates. B. PLACE OF SERVICE: Place of Service (POS)) codes are printed below. Please refer to that list and place the appropriate code in the space provided. C. PROCEDURE CODE: Identifies the procedures used. Enter the appropriate code and describe the procedure. Enter only one code per line. D. CODE MODIFIER: Not applicable. E. DENTAL: Not applicable. F. HOME NURSING: Number of Hours or Days: Enter number of hours per day or number of days per month. Hourly or Daily Rate: Record the rate charged (by the hour or day) for the home nursing services provided. G. GLASSES: Not applicable. H. CHARGES: Total line item charge. I. UNIT: The total hours if an hourly rate was entered in the home nursing column (item "F") or total of days if a daily rate was entered in the home nursing column (item "F"). 14. PROVIDER'S OR SUPPLIER'S NAME, ADDRESS, ZIP CODE AND TELEPHONE NUMBER: The provider's or supplier's name and current address. If any of the information changes, notify Provider Accounts immediately. (Indicating a new address on the bill will not change the department's record of address for the provider. 15. PROVIDER NUMBER: Enter Department of Labor and Industries provider account number. 16. NPI: Enter the national provider identifier. 17. TAXONOMY: Enter the ten -digit taxonomy code. 18. TOTAL CHARGE: Total of all charges for services provided. 19. YOUR PATIENT'S ACCOUNT NUMBER: The number used to identify your patient's account. 20 BILL DATE: The date your billing was prepared. 21. TAX IDENTIFICATION NUMBER: The provider taxpayer identification number for IRS (Internal Revenue Service) reports. 22. REMARKS: Any further information necessary to explain your charge. ATTACHMENTS Must have the corresponding claim number listed in the upper right corner of the attachment. DUE TO THE FACT THAT THE CRIME VICTIMS' BILL RECORDS ARE KEPT ON MICROFILM, BILLS AND ATTACHMENTS MUST BE LEGIBLE AND CLEAR. The following attachment is not acceptable: Office Visit Slips. REBILLS If you do not receive payment or notification from the department within ninety (90) days, services may be rebilled. Rebills should be identical to the original bill: same charges, codes and billing dates. Please indicate "Rebill" on the bill. Any inquiries regarding adjustment of charges must be submitted within ninety (90) days from the date of payment to be considered. PLACE OF SERVICE (POS) 03. School 04. Homeless Shelter 05. Indian Health Service Free-standing Facility 06. Indian Health Service Provider-based Facility 07. Tribal 638 Provider-based Facility 08. Tribal 638 Provider-based Facility 09. Correct
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