STATEMENT FOR HOME NURSING SERVICES Dept of Labor and Industries Claims Section PO Box 44269 Olympia WA 98504-4269 DO NOT WRITE IN SPACE Worker's full name Last First Middle SSN (ID only) Address Claim Number Employer's Name City State ZIP Reimburse Claimant Date of Injury Name of referring physician or other source DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (use ICD-9-CM) Designate left or right when applicable 1. 2. 3. 4. 5. FROM DATE OF SERVICE Yes No Referring physician provider number / NPI For glasses, advise if old Rx was available Yes No Give hospitalization date for inpatient services Admitted REFUND CERTIFICATION I hereby certify under penalty of perjury that this is a true and correct claim for the necessary expenses incurred by me, that the claim is just and due and that no payment has been received by me on account thereof. CLAIMANT'S SIGNATURE: Discharged * POS PROC CODE MOD CODE Describe procedures, medical services or supplies furnished. Attach lab reports, X-ray findings and any special services Dental Tooth Number Home Nursing No. of Hourly/ hrs/day Day rate GLASSES OLD RX NEW RX OD OS OD OS CHARGES $ ¢ Unit TO DATE OF SERVICE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 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. Signature: Bill date: Provider or Supplier name Provider Number NPI Address Taxonomy Total Charge City State Federal tax ID number EIN ZIP+4 SSN Phone Number Your Patient's Account Number Remarks: * Place of Service (POS) codes on back F248-160-000 statement for home nursing services 10-06 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR COMPLETING HOME NURSING SERVICES STATEMENT 1. INJURED WORKER'S NAME: Injured worker's full name, last name first. 2. SOCIAL SECURITY NUMBER: Record claimant's social security number. It is helpful when the claim number is wrong and the worker's name is common. 3. CLAIM NUMBER: For the injured worker receiving services. INDUSTRIAL Claim numbers are six digits, preceded by a "B, C, F, G, H, J, K, L, M , N, P, X, Y or double alpha followed by 5 digits". Crime Victim claim INSURANCE numbers are six digits preceded by a "V" or five digits preceded by a "VA, VB, VC, VH, VJ, VK, VL or VS". Department of Energy claims are seven digits with no preceding letter. Send bills for Industrial Insurance claims to: Send bills for Crime Victims claims to: Department of Labor and Industries Department of Labor and Industries PO Box 44269 PO Box 44520 Olympia WA 98504-4269 Olympia WA 98504-4520 Department bill forms are furnished at no charge to the vendor and can be obtained by calling the local department service location. Self-Insurance claim numbers are six digits preceded by an "S, T, W", or double alpha (SA-SZ, TA-TZ, WA-WZ). Bills for all self-insurance SELF INSURANCE claims should be sent directly to the employer or their service company. Department bill forms, self-insured forms, or other forms acceptable to the self-insurer may be used. 4. 5. 6. 7. ADDRESS: The injured worker's most current address. EMPLOYER'S NAME: The injured worker's employer's name. If the claim number is in error, this helps identify the proper claim. REIMBURSE CLAIMANT: Place an "X" in the applicable box. If payment should be made to the claimant, indicate the amount paid. 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. The date of injury positively identifies each claim. 8. NAME OF REFERRING PHYSICIAN: The name of the physician who has referred the claimant to you, the provider, for services. 9. REFERRING PHYSICIAN PROVIDER NUMBER / NPI: The Department of Labor and Industries provider account number or NPI of the referring physician. The number may be obtained from the referring physician. 10. DIAGNOSIS: Not applicable. 11. FOR GLASSES: Not applicable. 12. SERVICES RELATED TO HOSPITALIZATION: If claimant was hospitalized, record the date admitted and the date discharged. 13. REFUND CERTIFICATION - FOR CLAIMANT REIMBURSEMENT: Signature of the claimant who received the care. 14. ITEMIZATION OF SERVICES AND CHARGES: A. DATE(s) OF SERVICE: Record the date for each service provided. For consecutive dates of service, (i.e., home nursing care, attendant care) record both beginning (from-date-of-service column) and ending (to-date-of-service column) dates. B. PLACE OF SERVICE: A complete list of Place of Service (POS)) codes are printed below. Please refer to that list and place the appropriate code in the space provided. C. PROCEDURE CODE: Identifies the procedures used. Procedure codes can be found in the Medical Aid Rules and Maximum Fee Schedule distributed by the Department of Labor and Industries. Enter the appropriate code and describe the procedure. Enter only one code per line. D. CODE MODIFIER: Not applicable. E. DENTAL: Not applicable. F. HOME NURSING: Number of Hours or Days: Enter number of hours per day or number of days per month. Hourly or Daily Rate: Record the rate charged (by the hour or day) for the home nursing services provided. G. GLASSES: Not applicable. H. CHARGES: Total line item charge. I. UNIT: The total hours if an hourly rate was entered in the home nursing column (item "F") or total of days if a daily rate was entered in the home nursing column (item "F"). 15. PROVIDER'S OR SUPPLIER'S NAME, ADDRESS, ZIP CODE AND TELEPHONE NUMBER: The provider's or supplier's name and current address. If any of the information changes, notify Provider Accounts immediately. (Indicating a new address on the bill will not change the department's record of address for the provider. 16. PROVIDER NUMBER: Enter the L&I provider account. 17. NPI: Enter the national provider identifier. 18. TAXONOMY: Enter the ten-digit taxonomy code. 19. TOTAL CHARGE: Total of all charges for services provided. 20. YOUR PATIENT'S ACCOUNT NUMBER: The number used to identify your patient's account. 21. BILL DATE: The date our billing was prepared. 22. TAX IDENTIFICATION NUMBER: The provider taxpayer identification number for IRS (Internal Revenue Service) reports. 23. REMARKS: Any further information necessary to explain your charge. ATTACHMENTS: Must have the corresponding claim number listed in the upper right corner of the attachment. DUE TO THE FACT THAT THE DEPARTMENT RECORDS ARE KEPT ON MICROFILM, BILLS AND ATTACHMENTS MUST BE LEGIBLE AND CLEAR. The following attachment is not acceptable: Office Visit Slips. REBILLS: If you do not receive payment or notification from the department within ninety (90) days, services may be rebilled. Rebills should be identical to the original bill: same charges, codes and billing dates. Please indicate "Rebill" on the bill. Any inquiries regarding adjustment of charges must be submitted within ninety (90) days from the date of payment to be considered. PLACE OF SERVICE (POS) 03. School 04. Homeless Shelter 05. Indian Health Service Free-standing Facility 06. Indian Health Service Provider-based Facility 07. Tribal 638 Provider-based Facility 08. Tribal 638 Provider-based Facility 09. Correctional Facility 11. Office 12. 13. 14. 15. 20. 21. 22. 23. 24. 25. 26. 31. Patient's Home Assisted Living Facility Group Home Mobile Unit Urgent Care Facility Inpatient Hospital Outpatient Hospital Emergency Rm - Hospital Ambulatory Surgical Ctr Birthing Ctr Military Trmt Facility Skilled Nursing Facility F248-160-000 statement for home nursing services - backer 10-06 32. 33. 34. 41. 42. 49. 50. 51. 52. 53. 54. 55. 56. Nursing Facility Custodial Care Facility Hospice Ambulance - Land Ambulance - Air or Water Independent Clinic Federally Qualified Hlth Ctr Inpatient Psychiatric Facility Psychiatric Facility Partial Hospitalization Community Mental Health Ctr Intermediate Care Facility/Mentally Retarded Residential Substance Abuse Trmt Facility Psychiatric Residential Trmt Ctr 57. Non-residential Substance Abuse Trmt Facility 60. Mass Immunization Center 61. Comprehensive Inpatient Rehabilitation Facility 62. Comprehensive Outpatient Rehabilitation Facility 65. End Stage Renal Disease Trmt Facility 71. State or Local Public Health Clinic 72. Rural Hlth Clinic 81. Independent Laboratory 99. Other Unlisted Facility American LegalNet, Inc. www.FormsWorkflow.com