C947 SUPPORT CARE SERVICES Invoice P.O. FAX: (780) 427-5863 1-800-661-1993 WCB Claim Number Personal Health Number Date of Accident (yyyy/mm/dd) Please print clearly or type. Worker’s Surname First Name Initial Date of Birth (yyyy/mm/dd) Address City/Town Province Postal Code Telephone Number ( ) SERVICES/REPORTING WCB Fee Amount Service Date Service/Reporting Description # of Units Code Submitted (yyyy/mm/dd) $ $ $ $ TRAVEL (including air fare & vehicle rental) Travel Description WCB Fee # of Amount Service Date Distance Code Units Submitted (Include start and end destination) (yyyy/mm/dd) (KM) $ $ $ $ MEALS & ACCOMMODATIONS (Receipts must be submitted where applicable) Amount Service Date Meals & Accommodations WCB Fee Code Submitted (yyyy/mm/dd) $ $ $ $ Total Amount Billed $ Name and Address to Whom Fee is Payable (print) Provider Signature Print Name WCB Billing Number: Telephone Number Fax Number TOP NOP: PR 58; PR 48 ( ) ( ) Skill Code: MULT Provider Reference Number Date (yyyy/mm/dd) Contract ID: 000039
P.O. FAX: (780) 427-5863 1-800-661-1993 C947 SUPPORT CARE SERVICES Invoice Please print clearly or type. WCB Claim Number Personal Health Number Date of Accident (yyyy/mm/dd) Worker’s Surname First Name Initial Date of Birth (yyyy/mm/dd) Address City/Town Province Postal Code Telephone Number ( ) SERVICES/REPORTING Service Date (yyyy/mm/dd) Service/Reporting Description WCB Fee Code # of Units Amount Submitted $ $ $ $ TRAVEL (including air fare & vehicle rental) Service Date (yyyy/mm/dd) Travel Description (Include start and end destination) WCB Fee Code # of Units Distance (KM) Amount Submitted $ $ $ $ MEALS & ACCOMMODATIONS (Receipts must be submitted where applicable) Service Date (yyyy/mm/dd) Meals & Accommodations WCB Fee Code Amount Submitted $ $ $ $ Total Amount Billed $ Name and Address to Whom Fee is Payable (print) WCB Billing Number: TOP NOP: PR 58; PR 48 Skill Code: MULT Contract ID: 000039 Provider Signature Print Name Telephone Number ( ) Fax Number ( ) Provider Reference Number Date (yyyy/mm/dd)
C947.docx