Statement For Crime Victim Misc Services {F800-076-000}

Mail completed forms to: Department of Labor and Industries PO Box 44520 Olympia WA 98504-4520 Type of Service: Dental Service Transportation Glasses Vocational/Retraining CRIME VICTIM STATEMENT FOR MISCELLANEOUS SERVICES Home Health / Nursing Home Other: Claim No. Date of injury Apt # State ZIP Social Security No. (for ID only) Phone no. L&I provider number NPI Federal Tax ID State ZIP Phone no. Referral ID Medical Equipment/ Prosthetics-Orthotics Claimant Information (Please print) Name (Last, First, Middle Initial) Home address (not PO Box) City Provider Information (Please print) Provider name Address City Name of referring physician or other source Referring provider number/NPI Billing Information For glasses, is the old Rx available? Yes No From Date of Service 1 2 3 4 5 6 7 8 9 10 To Date of Service POS Proc Code Mod Mod Dx Is this bill to reimburse the claimant? Yes (Receipt and signature required) For inpatient services: Describe procedures, medical services or supplies furnished. Dental tooth # Home Nursing No. of Hourly/ hrs/day Day rate No Date admitted:__________ Date discharged: ____________ Charges Units Total Charge $ Claimant Signature: These expenses are related to my workers' compensation claim and I have not been reimbursed for them. I understand it is a crime to submit information I know is false. Signature (Required for worker reimbursement) Date Provider Signature: I certify that the information in the bill is true and correct. I have not been reimbursed for any part of this bill. Signature Date American LegalNet, Inc. www.FormsWorkFlow.com F800-076-000 Crime Victim Statement for Miscellaneous Services 07-2013 Instructions for completing the Crime Victim Statement for Miscellaneous Services: Type of Service: Check the appropriate box for the type of service for which you are billing. If your type of service is not listed, check the "Other" box and list the type of service you provided. Worker Information: Claim number Name Date of injury Home address Social Security Number Phone number Provider Information: L&I provider number Provider name Provider address NPI Federal Tax ID Phone number Name of referring physician or other source Referring provider number/NPI Referral ID Bill Information: Is this bill to reimburse the claimant? For glasses, is the old Rx available? For inpatient services Give the claim number. Write the claimant's legal name in the last, first, middle initial format. Date of injury. Give the most current physical address of the claimant. Write the claimant's Social Security Number. Used to verify claim number only. Write the claimant's phone number. Give the provider's L&I provider number. Write the provider's name as registered with L&I. Write the provider's physical address. Give the provider's NPI. Write the Federal Tax ID (EIN) for the billing provider. This must match the EIN on file with the agency. Give the phone number where the agency can call if there any questions about your bill. Write the name of the referring physician or other source for the services provided. Write the L&I provider number or NPI of the referring provider Write the referral ID number. Check the appropriate box. If this bill is to reimburse a claimant, receipts are required. Send copies of your receipts. Receipts must be itemized and legible. No credit card slips. Check the appropriate box. Write date of admission and the date of discharge in the mm/dd/yy format. Use one line for each service provided. Complete each applicable field. From date of service Starting date of service. To date of service Ending date of service. POS Place of service. See the list below for the appropriate two-digit code. Proc Code Procedure code. Mod Modifier code if applicable. Dx Diagnosis code. Enter the primary diagnosis code for each service. Description Give a brief description of services provided. Dental tooth number Tooth number dental services were provided for. Home nursing Give the number of hours you are billing for. Give your hourly or daily rate for your services. Charges Enter the charge for each service provided. Units Enter the number of units for service. Place of Service Codes 03. School 04. Homeless shelter 22. Outpatient hospital 23. Emergency room - hospital 24. Ambulatory surgical center 25. Birthing center 26. Military treatment facility 31. Skilled nursing facility 32. Nursing facility 33. Custodial care facility 34. Hospice 41. Ambulance - land 42. Ambulance - air or water 49. Independent clinic rehabilitation facility 50. Federally qualified hlth ctr 51. Inpatient psychiatric facility 52. Psychiatric facility partial hospitalization 53. Community mental health ctr 54. Intermediate care facility/mentally retarded 55. Residential substance abuse trmt center 56. Psychiatric residential trmt ctr 57. Non-residential substance abuse treatment center 60. Mass immunization center 61. Comprehensive inpatient rehabilitation facility 62. Comprehensive outpatient 65. End stage renal disease treatment facility 71. State or local public health clinic 72. Rural health clinic 81. Independent laboratory 99. Other unlisted facility 05. Indian Health Service free-standing facility 06. Indian Health Service provider-based facility 07. Tribal 638 free-standing facility 08. Tribal 638 provider-based facility 09. Correctional facility 11. Office 12. Patient's home 14. Group home 15. Mobile unit 16. Temporary lodging 17. Walk-in retail health center 20. Urgent care facility 21. Inpatient hospital F800-076-000 Crime Victim Statement for Miscellaneous Services 07-2013 American LegalNet, Inc. www.FormsWorkFlow.com