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Form 65D2_ WorkSafeBC

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Form 65D2_ WorkSafeBC Powered By Docstoc
					                                                       VOCATIONAL REHABILITATION SERVICES
                                                              EXTERNAL PROVIDER NETWORK
                                                   RESET                  SERVICE INVOICE

This invoice must be submitted within 90 days of the date of service. Please FAX or mail completed form to WorkSafeBC as
indicated below. All fields with* are required for payment to be processed. Failure to provide this information may result in
processing delays. Please complete all other fields (if possible). Incomplete invoices may be returned for resubmission.
PAYMENT SERVICES                                 FAX                                           MAIL
Phone 604 276-3085                               604 233-9777                                  WorkSafeBC
Toll-free 1 888 422-2228                         Toll-free 1 888 922-8807                      PO Box 4700 Stn Terminal
                                                                                               Vancouver BC V6B 1J1
Invoice number                                     Invoice date* (yyyy-mm-dd)                          Contract ID


Service location code                              Authorization number*                               Referring VRC


Payment information
Provider (Payee/Agency) name                       Payee number*               Personnel last name                   First name


Mailing address for payment                                                    City                                  Province           Postal code*

Telephone number (please include area code)                                    Fax number (please include area code)


Service recipient information (worker or other person who received service)
Service recipient last name*                                                   Service recipient first name*


Service recipient date of birth* (yyyy-mm-dd)                                  WorkSafeBC claim number*


Date of injury (yyyy-mm-dd)                                                    Service recipient personal health number (CareCard number)


Service information
                                                                                                           Cost per unit*
                                                                                                         (please provide only
   Date of                                                                            Number              one per fee code)
   service                                                                            of units*
    end*           Fee                      Fee description*                      (number of hours,    Maximum         Rate per          Line item
 (yyyy-mm-dd)     code*                     (services provided)                  services, or weeks)   billable $       hour             amount*
                 1101001      Vocational interest and aptitude testing                                    500
                              Vocational interest and aptitude testing PLUS
                 1101002                                                                                  850
                              achievement testing
                 1101003      Psycho-vocational testing/assessment                                        1800
                              Psycho-vocational testing/assessment PLUS
                 1101004                                                                                  2125
                              learning disability testing
                              Document review, psycho-vocational
                 1101054                                                                                  250
                              assessment
                 1101015      Resumé and cover letter preparation                                         250

                 1101019      Job finding club                                                            1900

                 1101020      Job search skills — individualized                                          1500

                 1101021      Job search skills — group size (two)                                        1250

                 1101021      Job search skills — group size (three or more)                              1000




                                                   Workers’ Compensation Board of B.C.                              65D2        (R01/10) Page 1 of 2
                                                                             Vocational Rehabilitation Services External Provider
                                                                                            Network Service Invoice (continued)


 Service recipient last name                                                     First name                                                                  WorkSafeBC claim number



                                                                                                                                                  Cost per unit*
                                                                                                                                               (please provide only
     Date of                                                                                                       Number                       one per fee code)
     service                                                                                                       of units*
      end*                  Fee                              Fee description*                                 (number of hours,             Maximum              Rate per                Line item
  (yyyy-mm-dd)             code*                             (services provided)                             services, or weeks)            billable $            hour                   amount*
                         1101016          Job placement individualized                                                                          1950

                         1101017          Job placement — supported                                                                             1950
                                          Job placement — extension (where applicable
                         1101023                                                                                                                 200
                                          and pre-approved) (200.00/wk)
                                          Job placement — durable placement —
                         1101024                                                                                                                 200
                                          permanent
                                          Job placement — durable placement —
                         1101024                                                                                                                 100
                                          temporary
                                          EDAP 1 — Worker compromised job
                         1101026                                                                                                                 150
                                          interview/opportunity
                                          EDAP 2 — Worker declined job
                         1101026
                                          interview/opportunity (1 x starting wk. salary)
                                          EDAP 3 — Durable placement (2.5 x starting
                         1101026
                                          wk. salary)
                                          Customized VR services ($75.00 per hour
                         1101018
                                          unless otherwise approved)
                                          Customized VR services ($75.00 per hour
                         1101018
                                          unless otherwise approved)
                         1101025          Travel time — pre-approved                                                                                                  50

                         1101025          Airfare — pre-approved

                         1101025          Accommodation — pre-approved

                         1101025          Meals — pre-approved

                         1101025          Vehicle rental — pre-approved

                         1101025          Ferry or tolls — pre-approved

                         1101025          Other travel expenses — pre-approved

                                                                                                                                                           Invoice total* $


 Comments




Personal information on this form is collected for the purposes of administering a worker’s compensation claim by WorkSafeBC in accordance with the Workers Compensation Act and the Freedom of
Information and Protection of Privacy Act. For further information about the collection of personal information, please contact WorkSafeBC’s Freedom of Information Coordinator at PO Box 2310 Stn Terminal,
Vancouver BC, V6B 3W5, or telephone 604 279-8171.




                                                                                                                                                            65D2           (R01/10) Page 2 of 2

				
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