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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 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).

 

Form F245-072-000
Statement for Home Nursing Services

Used to bill L&I for reimbursement of home nursing services.

Form F248-160-000

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