Service Invoice 1. Bill type (Please check one) Instructions · Complete all applicable portions of this fee bill and mail to the appropriate party, either BWC or the MCO. · Mail all documentation to the local customer service office. · For instructions on how to complete this invoice, refer to the BWC's Billing and Reimbursement Manual. 2. Claim number (K) (N) (P) (R) (V) Dental Nursing Practitioner Vocational rehabilitation Other vendor 4. Date of injury 3. Injured worker Social Security number 5. Injured worker's name (last, first and middle initial) 6. Injured worker's address (street or P Box, city, state and ZIP code) .O. 7. Referring physician provider number 8. Referring physician name 9. Prior authorization number (if applicable) 10. Patient account number (15 max) 11. Provider number 12. Provider name 13. Check here if total payment is to be made to injured worker 14. Group payee number (if different from provider number) 15. Service date 16. 17. 18. 19. Place Procedure Diagnostic of code Modification code service CPT/HCPCS code ICD-9-CM 20. Description of service 21. Charges 22. 23. Units of Tooth service No. I hereby certify the information contained on this form is true and correct to the best of my knowledge and belief. 26. Total charge 24. 27. Remarks Provider signature Date 28. Payee name, address, city, state, ZIP code and telephone number (print, stamp or type) 25. I certify the information on this form is true and correct. I understand that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain payment as provided by BWC, or who knowingly accepts payment to which that person is not entitled is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. BWC-1124 (Rev. 9/21/2010) C-19 American LegalNet, Inc. www.FormsWorkFlow.com