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  • Workcomp Payment Verification

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    Brandy Powell Hall
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    This document is a workers compensation payment verification form containing information about a patient including their name, address, date of birth, claim number, employer, date of injury, diagnosis, doctor's name and phone number. It lists several items with dollar amounts and indicates whether they are for purchase or rental. The form is signed and includes the printed name, title, and date of the signer authorizing payment for the listed items to be sent to the specified billing address.

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    This document is a workers compensation payment verification form containing information about a patient including their name, address, date of birth, claim number, employer, date of injury, diagnosis, doctor's name and phone number. It lists several items with dollar amounts and indicates whether they are for purchase or rental. The form is signed and includes the printed name, title, and date of the signer authorizing payment for the listed items to be sent to the specified billing address.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    16 views2 pages

    Workcomp Payment Verification

    Uploaded by

    Brandy Powell Hall
    This document is a workers compensation payment verification form containing information about a patient including their name, address, date of birth, claim number, employer, date of injury, diagnosis, doctor's name and phone number. It lists several items with dollar amounts and indicates whether they are for purchase or rental. The form is signed and includes the printed name, title, and date of the signer authorizing payment for the listed items to be sent to the specified billing address.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    WORKERS COMPENSATION PAYMENT

    VERIFICATION
    Patient Name:
    ___________________________________________________________
    Patient Address:
    __________________________________________________________
    Patient DOB: _______________ Claim Number:
    _______________________________
    Employer:
    ______________________________________________________________
    P.O. or Authorization
    #____________________________________________________
    Date of Injury: ______________________ DX:
    _________________________________
    Dr's Name: ____________________________________
    Phone#___________________
    Length of need_________________________________________________
    Item: ______________________
    $__________

    Purchase $__________

    Rental

    Item: ______________________
    $__________

    Purchase $__________

    Rental

    Item: ______________________
    $__________

    Purchase $__________

    Rental

    Item: ______________________
    $__________

    Purchase $__________

    Rental

    I hereby authorize payment of the above item/s to


    _______________________________
    _______________________________________________________
    Signature
    _____________________________________
    Title

    _______________________________________________________
    Printed Name
    _____________________________________
    Date
    Send bill to
    address:________________________________________________________
    _______________________________________________________________________
    _
    _______________________________________________________________________
    _

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