Claim For Home Nursing Services {WSCD-6A}

CLAIM FOR HOME NURSING SERVICES WYOMING DEPARTMENT OF WORKFORCE SERVICES DIVISION OF WORKERS' COMPENSATION 307-777-7441 PLEASE PRINT OR TYPE IN BLACK INK Injured Worker Information CASE # SSN # Date of Birth Provider Information FEDERAL TAX ID # OR SOCIAL SECURITY # Required for payment NAME ADDRESS CITY PHONE # ( ) STATE ZIP DATE OF INJURY NAME ADDRESS CITY STATE ZIP RATE PER HOUR Service Dates FROM: TOTAL DAY ACTUAL TIME FROM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM Service Dates TO: TOTAL DAY ACTUAL TIME FROM TO AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM HOURS AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM CHARGES HOURS CHARGES TO TOTAL I hereby certify under penalty of perjury, that all times shown on the above bill are accurate and actual hours worked by me personally. Provider Signature (required) INSTRUCTIONS FOR FILING: Date Submit billing no later than the 30th of each month for prior month's services or CLAIM MAY BE DENIED MAIL ORIGINAL TO: WSCD-6A (Rev 08/11) Division of Workers' Compensation PO Box 20070 Cheyenne, WY 82003-7001 American LegalNet, Inc. www.FormsWorkFlow.com