Statement for Miscellaneous Services

Document Information
  How to complete a fillable form.
Title Statement for Miscellaneous Services

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].


Document number F245-072-000
How to get this document
  • Order it from our Warehouse
  • Alt Language(s) Español
    Valid dates 01/2014
    Contact information Managing Injured Workers' Claims , Vocational Resources
    Websites For Medical Providers

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