Department of Labor and Industries Crime Victims Compensation Program PO Box 44520 Olympia WA 98504-4520 STATEMENT FOR CRIME VICTIM MENTAL HEALTH SERVICES Claim Number VClaimant's full name Last Address City State ZIP First Middle Social Security Number (for ID only) Date of Birth BE SURE TO INCLUDE YOUR PROVIDER NUMBER AND YOUR PATIENT'S CLAIM NUMBER OR YOUR BILL MAY BE DENIED. Date of Injury DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (ICD Diagnosis Codes). Designate left or right when applicable. 1. 2. 3. 4. 5. ENTER ONLY ONE ITEM PER LINE Date of Service POS Procedure Code Mod Code Describe services provided If mental health patient is not victim, give name and the relationship to victim. Charges $ Unit To Date of Service 1. 2. 3. 4. 5. 6. 7. The submission of this bill certifies that the material furnished, service(s) provided, expense incurred, or any 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. Signature Bill date Amount Paid by Primary Insurance $ Provider of Service Name Group, Clinic, Center or Facility Name Individual Provider No,/NPI Group Provider No./NPI Total Charge Phone Number Address City Federal Tax ID Number Name of Primary Insurance Company State EIN ZIP SSN Your Patient's Account Number PLEASE ATTACH A COPY OF THE EXPLANATION OF BENEFITS OR YOUR BILL MAY BE DENIED American LegalNet, Inc. www.FormsWorkFlow.com F800-025-000 Statement for Crime Victim Mental Health Services 08-2013 Instructions for Completing Crime Victims Mental Health Services Billing Form Crime Victims is a secondary insurer. Submit bills to public or private insurance first. You must attach Primary EOB to your bill. Worker Information Claim Number Claimant's Name Social Security Number Date Of Injury Address Date Of Birth Diagnosis Date Of Service Enter claimant's crime victim claim number. Write the claimant's last name, first name and middle initial format. Enter claimant's social security number. Used to verify claim number only. The date of injury. Enter claimant's current address. Enter claimant's date of birth. Enter ICD code number and the narrative diagnosis for all conditions treated. Enter the month, day and year of service. (e.g., January 04, 2002 = 010402). When billing for more than one date of service, only consecutive days may be billed on the same line. If dates of service are not consecutive, list each date on a separate line. Place of Service codes are printed below. Enter appropriate code in space provided. Enter the procedure code for the service performed or item provided. Enter only one code per line. Modifier code if applicable. Enter brief description of services provided. Enter patient's name and relationship to claimant. Enter your usual and customary fee for the procedure billed on this line. Do NOT bill negative charges. Enter the total number of times a procedure is provided per line. Total of all charges. Enter the provider's name. Enter the provider of service provider number. Enter the provider's National Provider Identifier (optional for Crime Victims Compensation Program). Enter provider's physical address. Total of all charges. Signature may be that of the provider or the person preparing the bill. Regardless of who signs the bill, the provider submitting the bill is responsible for its accuracy. If the bill is prepared by computer, the signature may be left blank. The date your billing was prepared. Required. If the provider account number is incorrect this information helps identify the correct provider. The number you use to identify your patient's account. This is for your convenience only. The Crime Victims Compensation Program is a secondary insurer, public and private insurance must be billed first. Enter amount paid by public or private insurance. Enter the name of the public or private insurance making payments on behalf of the claimant. Itemization of Services and Charges Place Of Service Procedure Code Code Modifier Describe Services Provided Relationship To Victim Charges Unit Total Charges Provider Of Service Name Provider Number: NPI Provider's Address And Phone Number Total Charge Signature Bill Date Federal Tax I.D. Number Patient's Account No Amount Paid By Primary Insurance: Name Of Primary Insurance Place of Service Codes 03. School 04. Homeless shelter 22. Outpatient hospital 23. Emergency room - hospital 24. Ambulatory surgical center 25. Birthing center 26. Military treatment facility 31. Skilled nursing facility 32. Nursing facility 33. Custodial care facility 34. Hospice 41. Ambulance - land 42. Ambulance - air or water 49. Independent clinic rehabilitation facility 50. Federally qualified hlth ctr 51. Inpatient psychiatric facility 52. Psychiatric facility partial hospitalization 05. Indian Health Service free-standing facility 06. Indian Health Service provider-based facility 07. Tribal 638 free-standing facility 08. Tribal 638 provider-based facility 09. Correctional facility 11. Office 12. Patient's home 14. Group home 15. Mobile unit 16. Temporary lodging 17. Walk-in retail health center 20. Urgent care facility 21. Inpatient hospital 53. Community mental health ctr 54. Intermediate care facility/mentally retarded 55. Residential substance abuse trmt center 56. Psychiatric residential trmt ctr 57. Non-residential substance abuse treatment center 60. Mass immunization center 61. Comprehensive inpatient rehabilitation facility 62. Comprehensive outpatient 65. End stage renal disease treatment facility 71. State or local public health clinic 72. Rural health clinic 81. Independent laboratory 99. Other unlisted facility F800-025-000 Statement for Crime Victim Mental Health Service ­ 08-2013 American LegalNet, Inc. www.FormsWorkFlow.com