Obtenga un formulario o publicación: dental
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| Título | Tipo | Número |
|---|---|---|
Instructions in Spanish for completing the form F245-072-000 Statement for Miscellaneous Services - Instrucciones para Completar el Formulario para Servicios Misceláneos Also available in: English Instructions in Spanish for completing the form F245-072-000 Statement for Miscellaneous Services |
Form | F245-072-999 |
Statement for Crime Victim Miscellaneous Services Used by the provider or supplier for reimbursement of the following services - dental, glasses, home health, nursing home serivces, medical equipment, prosthetics-orthotics, transportation, vocational, retraining and other. |
Form | F800-076-000 |
Statement for Miscellaneous Services Also available in: Spanish 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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Form | F245-072-000 |
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