C776 HOME HEALTH CARE SERVICES P.O. BOX 2415 EDMONTON,AB T5J 2S5 Non-Authorized Provider Invoice Cover Sheet FAX: 780 427-5863 1-800-661-1993 WCB Claim Number Please print clearly or type. Worker’s Surname First Name and Initial Personal Health Number Date of Birth (yyyy/mm/dd) Date of Accident (yyyy/mm/dd) Address City/Town Province Postal Code Telephone Number NOTE: Billing Start Date and End Date must be within the same calendar month Billing Start Date Billing End Date (yyyy/mm/dd): (yyyy/mm/dd): Name and Address to Whom Fee is Payable (print) Signature Print Name Telephone Number Fax Number Provider Reference Number Date (yyyy/mm/dd) Service Code: RCF01
P.O. BOX 2415 EDMONTON,AB T5J 2S5 FAX: 780 427-5863 1-800-661-1993 C776 HOME HEALTH CARE SERVICES Non-Authorized Provider Invoice Cover Sheet Please print clearly or type. WCB Claim Number Worker’s Surname First Name and Initial Personal Health Number Date of Birth (yyyy/mm/dd) Date of Accident (yyyy/mm/dd) Address City/Town Province Postal Code Telephone Number NOTE: Billing Start Date and End Date must be within the same calendar month Billing Start Date (yyyy/mm/dd): Billing End Date (yyyy/mm/dd): Name and Address to Whom Fee is Payable (print) Service Code: RCF01 Signature Print Name Telephone Number Fax Number Provider Reference Number Date (yyyy/mm/dd)