Statement for Retraining and Job Modification Services

Document Information
  How to complete a fillable form.
Title Statement for Retraining and Job Modification Services

Bill form for providers that bill the department for claim-related retraining and job modification services. See the General Provider Billing Manual (248-100-000) for information on completing this form.

Document number F245-030-000
How to get this document
Alt Language(s) Español
Valid dates 03-2014, 08-2013
Contact information Claims for Job Injuries, Managing Injured Workers' Claims
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