Workers Compensation Medical Billing Form

Document Sample
Workers Compensation Medical Billing Form Powered By Docstoc
Worker's Name and Address

Worker's Comp
Claim No.: Date of Birth DD MM YY Date of Injury Personal Health No. Off Work Social Security No.: Estimated Date of Return to Work Fee Schedule Amount

Employer's Name and Address

Referral from Dr. Diagnosis DD

Treatment Date MM YY

Fee Schedule Code

Treatment or remarks

Note: Your account containing complete and legible information will assist the Board in processing your payment.

Clinic No.: Signature Doctor No.:

Locum No.: Telephone No.:

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