F245-030-000 Statement for Retraining and Job Modification Services 12-2017 Mail completed form to: PO Box 44269 Olympia WA 98504-4269 Statement for Retraining and Job Modification ServicesTo bill for Option 2 training, use the Statement for Option 2 Training (F245-446-000) form. Worker Information Reired lease rint Claim No. Name (Last, First, Middle Initial) Date of Injury Home Address Apt # Social Security No. (For ID Only) City State Zip Code Phone Number rovider Information lease rint L&I Provider Number Name (Last, First, Middle Initial) Federal Tax ID AddressPhone Number City State Zip Code ocational Reabilitation onselor Information Referral ID Vocational Rehabilitation Counselor Name VRC ID (L&I Provider Number) Billing Information (See Back for Instructions) From Date of Service To Date of Service S TS rocedre Code Description of Services or Spplies Units Charges 99 V 99 V 99 V 99 V 99 V 99 V 99 V 99 V 99 V 99 V Signatre (Only one signature is required. Sign under the appropriate section) Total Charge $ Is this a bill to reimburse the worker? Is this a bill for provider payment? es Include copies of receipts and sign below. es Sign below.These expenses are related to my workers222 compensation claim and I have not been reimbursed for them. I understand it is a crime to submit information I know is false. I certify that the information in the bill is true and correct. I havenotbeen reimbursed for any part of this bill. Worker222s Signature Date Provider222s Signature Date 1 2 3 4 5 6 7 8 9 10 American LegalNet, Inc. www.FormsWorkFlow.com F245-030-000 Statement for Retraining and Job Modification Services 12-2017 Instrctions for Completing the Statement for Retraining and Job Modification Services To bill for Option 2 training, use the Statement for Option 2 Training (F245-446-000) form. Worker Information Claim Number Enter the worker222s L&I claim number. Name Write the worker222s legal name in the last name, first name, middle initial format. Date of Injury Enter the date of injury. Home Address Write the most current physical address of the worker. Social Security Number Enter the worker222s Social Security Number. Used to verify the claim number. Phone Number Enter the phone number where the agency can call if there are any question about this bill. rovider Information L&I Provider Number Enter the provider222s L&I provider number. Provider Name Write the provider222s name as registered with the department. Provider Address Write the provider222s address. Federal Tax ID Enter the Federal Tax ID (EIN) for the billing provider. This must match the EIN on file with the agency. Phone Number Enter the phone number where the agency can call if there are any question about this bill. ocational Rehabilitation Conselor Information Referral ID Write the Referral ID. Vocational Rehabilitation Counselor Name Write the provider222s name as registered with the department. VCR ID Write the VCR ID. This is the L&I provider number for the VRC. Bill Information Use one line for each service provided. Complete each applicable field. From Date of Service Enter the starting date of service. To Date of Service Enter the ending date of service. Procedure Code Enter the appropriate code from the list below. One code per line. Description Write a brief description of the services provided. Units Enter the total number of units you are billing for. Charges Enter the charge for each service provided. Total Charges Enter the total for all of the charges on the bill. Retraining Codes Job Modification/Pre-Job Accommodation Codes: Lodging and Retraining Codes: Retraining Codes: Retraining Transportation Codes: 0380R Job Modification equipment 0385R Pre-job accommodation equipment 0389R Job Modification/Pre-job accommodation consultation 0391R Travel/Wait 0392R Mileage 0393R Ferry R0360 Board (food) and utilities R030 Rent 0375R One-time relocation fee (for life of claim) R0310 Tuition, training fees R0312 Supplies equipment, tools, books R0320 Exam, license fee R0350 Other R0390 Child care services 0302R Parking 0303R Bridge and ferry toll 0304R Commercial transportation Signatre Only one signature is required. Worker Signature If the bill is to reimburse the worker, the worker must sign and date the form. Attach copies of the receipts. All receipts must be itemized and legible. Provider Signature If the bill is to reimburse the provider, the provider must sign and date the form. American LegalNet, Inc. www.FormsWorkFlow.com