Department of Labor and Industries Send original to insurer. See list on back. Interpreter: Keep a copy for your records. Worker Information Worker Name (Last Name, First Name, Middle Initial) Interpretive Services Appointment Record Claim Number ICN ­ If you have billed the department using Direct Entry, write the ICN you received for this appt. Date of Injury (Use mm/dd/yy format) / Interpreter Information Interpreter's Name (Last, first, middle initial) / Interpreter's Provider Number Agency's Name (If applicable) Agency's Group Number Appointment Information Type of appointment ­ write the type of appointment such as diagnostic, doctor, vocational, etc. Appointment Date (Use the mm/dd/yyyy format) Language Requested / / Healthcare or Vocational Provider's Name (Last Name, First Name) Billing Information Is this a group service? No Yes Is this the first or last appointment of the day? Starting Street Address Appointment Street Address Return or Next Appointment Street Address Number of people in the group No ­ will need to prorate mileage. City City City State State State Yes Zip Code Zip Code Zip Code Arrival Time: Scheduled Start Time: Actual Start Time: End Time: Total Billable Minutes: : : : : A. Mileage to Appointment: B. Mileage to Return/Next Appointment: C. Number of People Split Between: D. Total Billable Mileage: Interpreter's Signature: By signing, I certify under penalty of perjury under the laws of the State of Washington that the information above is a true and correct statement of the interpretive services I provided. Interpreter's signature Date Interpreter Service Verification (This section is to be completed by the health care or vocational provider or their designee) · Do not sign unless the information above is completed. Keep a copy of this form for the provider's records. Print name of person verifying services Title Provider's NPI or L&I Provider Number Signature of person verifying services Date Phone Number American LegalNet, Inc. www.FormsWorkFlow.com F245-056-000 Interpreter Service Appointment Records 06-2015 Index: TSAR Instructions for completing Interpretive Services Appointment Record · · A completed ISAR and mileage documentation must be in the claim file by the time your bill is processed to avoid bill denial. Complete billing rules and instructions can be found online at: www.Lni.wa.gov/FeeSchedules/ in the Fee Schedules and Payment Policies (MARFS) ­ Chapter 14 Interpretive Services Complete the entire form. See below for detailed information on our most questioned fields. Worker Information: Worker Name ICN Enter the worker name in the last name, first name, middle initial format. If there aren't enough spaces for the entire worker name, enter as much of the name as possible. If you bill for interpretive services using L&I's Provider Express Billing (PEB) Direct Entry, enter the internal control number (ICN) assigned to the bill you submitted. The ICN assigned to your bill can be found in the Adjust Direct Entry Bills function of PEB for the claim number and date of service (DOS) billed. Please note ­ ICNs are only immediately available during PEB's normal operating hours of Monday ­ Friday, 6:00 am to 6:00 pm, excluding state holidays. If you submit your bill outside of normal operating hours, your ICN won't be available until normal operating hours. Interpreter Information: Interpreter's Name Enter the name of the person who provided the interpretation services. If there aren't enough spaces for the entire interpreter's name, enter as much of the name as possible. Interpreter's Provider Enter the L&I provider payment number assigned to the interpreter who provided the Number interpretation services. Agency's Name If the interpreter provided services on behalf of an interpretation agency, write the agency's name. If there aren't enough spaces for the entire agency name, enter as much of the name as possible. Agency's Group Number Enter the L&I provider payment number assigned to the interpretation agency. Appointment Information: Type of Appointment Write the type of appointment for provided interpretive services, such as doctor, diagnostic, vocational, etc. Billing Information: Group Service If this is for a group service, check the "Yes" box. In the space provided, write the number of people in the group. Group service time must be divided between ALL clients in the group. For more information, please refer to the Fee Schedules and Payment Policies (MARFS) ­ Chapter 14 Interpretive Services (see the link above). Check the appropriate box. If this is not the first or last appointment of the day, you will need to split the mileage between the L&I client and the next client ­ regardless of who the next client is. For more information, please refer to the Fee Schedules and Payment Policies (MARFS) ­ Chapter 14 Interpretive Services (see the link above). First or Last Appointment of the Day How to submit your bill: Mail your bill or use our Direct Entry Billing. Do not fax your bill. How to submit your ISAR: Submit the original to the insurer. Use addresses and fax numbers below only for the ISAR and mileage documentation. State Fund Department of Labor and Industries PO Box 44291 Olympia WA 98504-4291 800-848-0811 or 360-902-6500 Fax: 360-902-4567 Crime Victims Compensation Department of Labor and Industries PO Box 44520 Olympia WA 98504-4520 800-762-3716 or 360-902-5377 Fax: 360-902-5333 Self-Insurer Varies ­ Call 360-902-6901 to obtain the insurer's phone number and address Or see the Self-Insurer list: www.Lni.wa.gov/SelfInsured American LegalNet, Inc. www.FormsWorkFlow.com F245-056-000 Interpreter Service Appointment Records 06-2015 Index: TSAR