C40 b REQUEST FOR PAYMENT FOR HOME HEALTH CARE CLAIMS DIVISION SFN 54303 (04/2017) 1600 E C entury A ve , S te 1 PO Box 5585 Bismarck ND 58506-5585 Telephone 800-777-5033 Toll Free Fax 888-786-8695 TTY (hearing impaired) 800-366-6888 Fraud and Safety Hotline 800-243-3331 www.workforcesafety.com SECTION 1 226 Injured worker222s information Claim number Injured worker222s (First name) (Last name) SECTION 2 226 Payment information (Enter rate, number of hours, and total for each service that has been provided) Date Time in Time out 572 Credentialed Care Medical & personal care including Certified Nurse222s Aides (CNA) 582 Non-credentialed Care Medical & personal care including family members, friends, or other hired personnel that are not certified 589 Homemaking Services Must be in conjunction with medical/personal care, including non- personal care hired to do cooking, cleaning, or running errands Other Rate Hours Total Rate Hours Total Rate Hours Total Rate Hours Total Total payment request American LegalNet, Inc. www.FormsWorkFlow.com REQUEST FOR PAYMENT FOR HOME HEALTH CARE (cont222d) Page 2 of 2 Claim number Injured worker222s (First name) (Last name) C40 b Form continued on next page. Submit all pages to WSI. SECTION 3 226 Activities and/or services provided Homemaking Bathing Dressing Eating/feeding Grooming Mobility/walking Toileting/bowel and bladder care Transferring Activities of daily l i ving Reminders for self-medication administration Housekeeping Laundry Planning and preparing meals Shopping Other Travel time to appointments Conversation Errands Mail/correspondence Telephone use Sunday Monday Tuesday Wednesday Thursday Friday Saturday Date Time in AM PM AM PM AM PM AM PM AM PM AM PM AM PM Time out AM PM AM PM AM PM AM PM AM PM AM PM AM PM Hours worked Initials Explain activities and/or services provided SECTION 4 226 Caregiver222s information and fraud warning/s ignature Name FEIN or Social Security number Certification/license number Address City State ZIP code Telephone number Fraud warning Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the receipt of income or an increase in income from employment, in connection with any claim or application for workers222 compensation benefits will forfeit any future benefits and may be guilty of a felony which is punishable by imprisonment, substantial fines, or both. These criminal penalties are applicable to all persons dealing with WSI, including injured workers, employers, medical providers, and attorneys. Signature By signing this form, I acknowledge that I have read and understand the fraud warning. I understand that falsifying this claim or making a false statement regarding this claim may be a felony, punishable by substantial fines and imprisonment. I authorize and agree that statements in this form are true and accurate. Signature Date American LegalNet, Inc. www.FormsWorkFlow.com REQUEST FOR PAYMENT FOR HOME HEALTH CARE (cont222d) Page 2 of 2 Claim number Injured worker222s (First name) (Last name) C40 b American LegalNet, Inc. www.FormsWorkFlow.com