Self Insurance Room And Board Cost Encumbrance
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Self Insurance Room And Board Cost Encumbrance Form. This is a Washington form and can be use in Self Insurance Workers Comp.
Loading PDF...
Tags: Self Insurance Room And Board Cost Encumbrance, F207-174-000, Washington Workers Comp, Self Insurance
~
SELF INSURANCE
Department of Labor and Industries
This form must be completed by a vocational
Rehabilitation counselor who has received a referral
from a self-insured employer.
BOARD & ROOM COST ENCUMBRANCE
Modification
Original
**** Counselor is responsible for sending
a copy of this form to each vendor ****
Claimant:
Date
Vendor Name
Vendor Name
Vendor Name
Claim Number
Vendor Name
Total
Funds
Billing Category
and Code
Provider No.
Provider No.
Provider No.
Provider No.
From:
To:
From:
To:
From:
To:
From:
To:
Board
(Food & Utilities)
Rent
(Room & Furniture)
Relocation
(1 time/life of claim)
Vendor Funds
Allocated
Dates of Service
Company
Phone No.
Assigned Vocational Counselor:
Employer or Service Representative
Not
Approved
Approved
FAX No.
Date
Date
Signature
Phone No.
Signature
F207-174-000 bd & rm cost encumbrance 5-05
American LegalNet, Inc.
www.USCourtForms.com
