Statement for Miscellaneous Services


Statement for Miscellaneous Services

Document Information
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Title	Statement for Miscellaneous Services (A fillable form - 177 KB PDF)
Description	Used for miscellaneous services of an injured worker. Such as: dental, glasses, medical equipment, transportation, home services, retraining, etc. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode.
Detail
Form number	F245-072-000
Availability	Order it
Keywords	claims, dental, eye glasses, glasses, home services, industrial insurance, insurance, medical equipment, miscellaneous services, orthotics, prosthetics, retraining, transportation, worker's compensation, workers compensation, workers' compensation
Languages	English , Spanish
Valid dates	08-2007
Contact information	Managing Injured Workers' Claims Vocational
Web pages	For Medical Providers