Statement for Miscellaneous Services
See also
| Document Information | ||
|---|---|---|
 Get help downloading & printing files.  How to complete a fillable form. |
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| Title |
Statement for Miscellaneous Services (A fillable form - 187 KB PDF)
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| Description | This bill form is used by providers and injured workers to bill the department for services such as dental care; glasses; medical equipment; nursing home services; interpreter services; services workers pay for out of pocket; and other services. Information on how to bill the department can be found in the General Provider Billing Manual (F248-100-000).
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| Detail | ||
| Form number | F245-072-000 | |
| Availability | Order it |
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| Keywords | claims, eye glasses, home services, industrial insurance, orthotics, prosthetics, retraining, transportation, worker's compensation, workers compensation, workers' compensation | |
| Languages | English , Spanish | |
| Valid dates | 04-2010 | |
| Contact information |
Managing Injured Workers' Claims
Vocational Resources |
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| Web pages | For Medical Providers | |
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