Statement for Miscellaneous Services

Statement for Miscellaneous Services - (Forms/Publications)
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Title Statement for Miscellaneous Services (A fillable form - 252 KB PDF)

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 number F245-072-000
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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 01-2014
Contact information Managing Injured Workers' Claims
Vocational Resources
Web pages For Medical Providers

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