EDMONTON by R4fQpPOC

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									                                                                                                           C641
                                                                                      HOME HEALTH CARE SERVICES
       P.O. BOX 2415
   EDMONTON, AB T5J 2S5
                                                                                                         Invoice
    FAX: (780) 427-5863
          1-800-661-1993
                                                       WCB Claim Number                Personal Health Number            Date of Accident (yyyy/mm/dd)
              Please print clearly or type.

Worker’s Surname                                       First Name                                      Initial           Date of Birth (yyyy/mm/dd)


Address                                                City/Town                       Province        Postal Code       Telephone Number
                                                                                                                         (          )
NOTE: Billing Start Date and End Date must be within the same calendar month

Billing Start Date (yyyy/mm/dd):                                          Billing End Date (yyyy/mm/dd):

 RN                     # of Hours            Rate       Amount             RN Assessment                         # of        Flat Rate      Amount
 Services                                     $58.94                                                             Hours
                                                                            Assessment                            N/A         $130.00
 Stat Holiday                                 $88.41                        (Includes First 3 Hours)
 Cancellation                                 $58.94                        RN Assessment                         # of            Rate       Amount
                                         Subtotal A                                                              Hours
                                                                            Assessment                                            $58.94
 LPN                    # of Hours            Rate       Amount             (Maximum of 4
                                                                            Additional Hours)
 Services                                     $37.27                        Reassessment                                          $58.94
 Stat Holiday                                 $55.91                        (Maximum of 3 Hours)

 Cancellation                                                                                                                Subtotal E
                                              $37.27
                                         Subtotal B                         Travel Time*               # of Hours                 Rate       Amount
                                                                            RN                                                    $58.94
 HCA                    # of Hours            Rate       Amount
                                                                            LPN                                                   $37.27
 Services                                     $29.20
                                                                            HCA                                                   $29.20
 Stat Holiday                                 $43.80                        Mileage*                     Distance                 Rate       Amount
 Cancellation                                 $29.20                                                   (kilometers)
                                         Subtotal C                         RN/LPN/HCA                                             $0.49
 RN                     # of Hours            Rate       Amount             * Prior authorization is required                Subtotal F
 Coordination                                                               Miscellaneous Expenses* (Receipts are required)
 Services                                     $58.94                        Service Date        Description                 Amount
 (1 Hour per 180                                                             (yyyy/mm/dd)
 Hours of Service)
                                         Subtotal D




 Rates effective as of December 1, 2009                                      * Prior authorization is required               Subtotal G
                                                                                                                              Add Subtotals A through G
                                                                    Total Amount Billed           $
Name and Address to Whom Fee is Payable (print)                       Signature


                                                                      Print Name
WCB Billing Number:
TOP NOP: MS 06                                                        Telephone Number                             Fax Number
                                                                      (         )                                  (          )
                                                                      Provider Reference Number                    Date (yyyy/mm/dd)



             THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.
C - 641 REV MAR 2010                                                                                                                             Page 1 of 1

								
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