C537A

PROSTHETIC AND ORTHOTIC SERVICES

P.O. BOX 2415
EDMONTON, AB T5J 2S5 Unlisted Device/Service Calculations Worksheet
FAX: 780-427-5863
1-800-661-1993
WCB Claim Number
WORKER DETAILS
Surname First Name and Initial Date of Birth (yyyy/mm/dd)

Date of Service (yyyy/mm/dd) Date of Accident (yyyy/mm/dd)

Please use this calculation worksheet to determine pricing for unlisted devices/services.

NOTE: For unlisted socks, sheaths, or sleeves ONLY, please enter the Invoice Price into Line B. Otherwise, leave this space blank.
ONLY Line A OR Line B should be completed – NOT both.
Manufacturer’s Invoice or Quote must be attached

Code: Item Description: Quantity: *Invoice Price: $

*If invoice price is in USD, please use the Bank of Canada exchange rate from the date of invoice and enter amounts in CAD.
A. Mark-up *excluding unlisted socks, sheaths, sleeves (Invoice Price x .12) $ 0.00
$ 0.00 Invoice Price (If any taxes on invoice please exclude and show tax on line D)

B. Mark-up for unlisted socks, sheaths, or sleeves ONLY (Invoice Price x .70) $ 0.00
$ 0.00 Invoice Price (If any taxes on invoice please exclude and show tax on line D)

C. Shipping, as per invoice: 0.00 (Shipping actual cost x 1.12) $ 0.00

D. Taxes Paid, as per invoice (Enter actual tax paid) $ 0.00

E. Labour (please use up to the closest ¼ hour multiplied by $185.77 per hour) $ 0.00
Indicate time needed: 0.00 (hrs and or portion)

**Self-Calculated total price: Invoice Price + A + B + C + D + E = $ 0.00

0Please use a C537 invoice to claim this amount

Name and address to whom fee is payable (please print). Provider Signature

Print Name

WCB Billing Number: Phone Number Fax Number

Date (yyyy/mm/dd) Provider’s Reference Number

THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.
INVOICE MUST BE SUBMITTED WITHIN 6 MONTHS OF SERVICE TO BE ELIGIBLE FOR PAYMENT.
C – 537A REV APR 2021 Page 1 of 1