Free F245-056-000 INTERPRETIVE SERVICES APPOINTMENT RECORD - Washington

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 Doctor PT or OT Hospital PCE Other

May be completed by Interpreter or Language Agency
Appointment date City Start time State Language requested

Vocational Pharmacy Diagnostic IME

Telephone number ( ) Comments

INTERPRETER INFORMATION
Name of interpreter (last, first, middle initial) 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

Completed by Interpreter
Interpreter's Provider Number Agency's Provider Number City City City State State State

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
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: Crime Victim Compensation State Fund Self-insurer
Department of Labor and Industries PO Box 44291 Olympia, WA 98504-4291 1-800-848-0811 360-902-6500 FAX 360-902-4566 360-902-4567 360-902-5230 360-902-6440 360-902-4292 360-902-4565 360-902-6252 360-902-6100 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: OTH

F245-056-000 interpretive services appointment record 11-08

RESET

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. Only mileage is payable when clients no show at medical or vocational appointments. 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 appointment record 11-08