Free F245-030-000 statement for retraining and job modification services - Washington

Dept of Labor & Industries Claims Section PO Box 44269 Olympia WA 98504-4269

STATEMENT FOR RETRAINING AND JOB MODIFICATION SERVICES
RESET

DO NOT WRITE IN SPACE

Instructions for completing form on the reverse side
Claim No. Date of injury Apt # State ZIP + 4 Social Security No. (for ID only) Reimburse Injured Worker

Worker's name Worker's home address (not PO Box) City

Please indicate Vocational Rehabilitation Counselors name and telephone number

VRC ID

FROM DATE OF SERVICE

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
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. PROVIDER SIGNATURE: Bill date: Provider name Address City Federal tax ID number State ZIP+4 Provider number Total Charge Phone Number Your Client's Account Number SSN

X

L&I must receive this statement within 12 months of the date of service or claim allowance.

F245-030-000 statement for retraining & job modification services 5-08

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REFERRAL ID

Yes

No

REFUND CERTIFICATION These expenses are related to my worker's compensation claim and I have not been reimbursed for them. I understand it is a crime to submit information I know is false. I have read and understand the instructions on the back of this form. INJURED WORKER'S SIGNATURE:

X
CHARGES $ ¢

Itemization of Service and Charges
P O S

*

T O S

PROCEDURE CODE

DESCRIBE SERVICES, OR SUPPLIES FURNISHED

UNIT

TO DATE OF SERVICE

/

/

EIN

* Place of Service (POS), Type of Service (TOS) and Procedure codes on back

INSTRUCTIONS FOR COMPLETING RETRAINING AND JOB MODIFICATION SERVICES FORM (Retraining & Job mods only) IMPORTANT: Retraining mileage must be billed on a Travel Expense Voucher form for injured worker reimbursement. Please call the provider hotline at 1-800-848-0811 for the correct reimbursement form, F245-145-000.
CLAIM NUMBER: For the injured worker receiving services.

STATE FUND INDUSTRIAL INSURANCE
Claim numbers are six digits, beginning with a "B, C, F, G, H, J, K, L, M, N, P, X, Y or double alpha followed by 5 digits." Send bills for Industrial Insurance claims to: Department of Labor and Industries PO Box 44269 Olympia WA 98504-4269

CRIME VICTIMS
Claim numbers are six digits beginning with a "V", or five digits proceeded by a "VA, VB, VC, VH, VJ, VK, VL or VS." Send bills for Crime Victims claims to:

Department of Labor and Industries PO Box 44520 Olympia WA 98504-4520

SELF-INSURANCE Claim numbers are six digits beginning with an "S, T, W", or double alpha (SA-SZ, TA-TZ, WA-WZ). Department of Energy claims are now Self-Insured. Claim numbers are seven digits beginning with "7, 8 or 9." Send bills to the employer or their service company.
INJURED WORKER'S NAME: Injured worker's full name, last name first. DATE OF INJURY: This is important and must be included. One worker may have several claims, so it is vital the proper claim be identified and charged for services provided. HOME ADDRESS: The injured worker's most current address (not PO Box). SOCIAL SECURITY NUMBER: Record injured worker's social security number. It is helpful when the claim number is wrong and the worker's name is common. REIMBURSE INJURED WORKER: Place an "X" in applicable box. VRC ID: L&I provider ID of Vocational Rehabilitation Counselor. REFERRAL ID: VRC's L&I referral number. WORKER'S SIGNATURE: Worker's signature is required for claimant reimbursements. Forms not signed will be returned. VOCATIONAL REHAB COUNSELOR'S NAME AND TELEPHONE NUMBER ITEMIZATION OF SERVICES AND CHARGES: Receipts required for worker reimbursement. FROM DATE(s) OF SERVICE: Record the date for each service provided (Note: for food only, a separate line is required for each receipt date). PLACE OF SERVICE (POS): Put code 99 in this box. TYPE OF SERVICE (TOS): Put type of service code "V" in this box. PROCEDURE CODE: Please refer to the list of procedure codes below. Choose a code that best describes your service and enter it in the box. DESCRIBE SERVICES OR SUPPLIES FURNISHED: Description of service(s) provided. CHARGES: Charges for service provided. Itemized, dated & business stamped RECEIPTS REQUIRED FOR WORKER REIMBURSEMENT. For food receipts, items purchased must have a description. (Please send receipt copies. Keep your original). UNIT: Number of days/units for the service billed on each line. TO DATE(s) OF SERVICE: Record the date for each service provided. (Note: for food only, a separate line is required for each receipt date). PROVIDER SIGNATURE: Signature required for any provider billings. Forms not signed will be returned. PROVIDER'S NAME, ADDRESS, ZIP CODE AND TELEPHONE NUMBER: If any of this information changes, call 1-800-848-0811 immediately. (Simply indicating a new address on the bill will not change L&I's record of address for the provider.) For further information, find us at:

www.Lni.wa.gov/claimsinsurance/providerpay/billing/provider
PROVIDER NUMBER: Identification number designated by the Department of Labor and Industries for the provider. TOTAL CHARGE: Total of all charges for services provided. YOUR CLIENT'S ACCOUNT NUMBER: The number used for providers to identify their client's account. CODES: JOB MODIFICATION PROCEDURES CODES: 0380R 0385R Job Modification Pre-Job Accommodation Equipment RETRAINING PROCEDURE CODES: Tuition, Training Fees R0310 Supplies R0312 Equipment, Tools R0315 Exam, License Fee R0320 Books R0340 Other R0350 Child Care Services R0390 LODGING & RELOCATION: R0360 R0370 0375R F245-030-000 statement for retraining & job modification services backer 5-08 Board (Food) and Utilities Rent One-Time Relocation Fee (for life-time of claim) RETRAINING TRANSPORTATION CODES: 0302R 0303R 0304R Parking Bridge and Ferry Tolls Commercial Transportation