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3947a Fs 06 16

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  • 80 other fields

Country of origin: CANADA
File type: PDF

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Prompt payment for Health Professionals and Providers
Our goal is to process your payment requests quickly and accurately. In order to avoid processing delays, complete all
fields of either the Provider Payment Request form or the Provider Payment Request for Equipment/Supplies form and
write legibly.
Incomplete or illegible payment requests will create processing delays.
Help on completing the forms
For help on completing the Provider Payment Request form or the Provider Payment Request for Equipment/Supplies
form, refer to the instruction sheets that are attached to these forms.
Questions
If you have any questions about how to complete these forms, bill for services, equipment, or supplies, or if you require
payment labels, please call our Health Professional Access Line at 416-344-4526 or 1-800-569-7919 between 8:30 a.m.
and 4:30 p.m. Monday to Friday.
Electronic Billing
If you are interested in electronic billing (excluding medical reports), contact our external payment provider, BCE Emergis
at 1-866-240-7492.
Important: Do not use the Provider Payment Request form to bill for medical reports.
To bill for medical reports, please complete the billing section on the pre-printed WSIB report
form, or place a payment label on the front page, bottom right hand corner of a narrative report.
Go To
Form
Provider Payment Request
or Fax to:
416-344-4684
OR 1-888-313-7373
Mail to:
200 Front Street West
Toronto ON M5V 3J1
Important: Do not use this form to bill for clinical reports.
Claim No.
Please complete in full
using black ink.
Worker Information
Worker Surname Given Name(s)
Initial Worker's Impairment and/or ICD 9 Code
(if available)
Address Date of Incident (mm/dd/yy)
City Prov. Postal Code Date of Birth (mm/dd/yy)
WSIB Reference No.
(For WSIB use only)
Provider/Facility Name and Full Address (city, province, postal code)
Provider Information:
WSIB Provider ID
HST Registration No.
Your Invoice No.
Please complete the address above this line.
Treating Provider's Name (please print)
fold
Telephone
Service/Treatment Information
Please use a separate line for each service code. Do not include previously billed services.
No. of
Serv/Trt.
Amount Billed
Description of Service/Treatment
Service Code Fee per Service
1.
Year 1 2 8
Month 3 4 5 6 7 9 10 11 12 13 14 15 16 17 18 20 22 25 26 27 28 29 30 31
19 21 23 24
No. of
Serv/Trt.
Amount Billed
Description of Service/Treatment
Service Code Fee per Service
Year 1 2 8
Month 3 4 5 6 7 9 10 11 12 13 14 15 16 17 18 20 22 25 26 27 28 29 30 31
19 21 23 24
No. of
Serv/Trt.
Amount Billed
Description of Service/Treatment
Service Code Fee per Service
3.
Year 1 2 8
Month 3 4 5 6 7 9 10 11 12 13 14 15 16 17 18 20 22 25 26 27 28 29 30 31
19 21 23 24
No. of
Serv/Trt.
Amount Billed
Description of Service/Treatment
Service Code Fee per Service
4.
Year 1 2 8
Month 3 4 5 6 7 9 10 11 12 13 14 15 16 17 18 20 22 25 26 27 28 29 30 31
19 21 23 24
Total
Billed
υ
(1 + 2 + 3 + 4 = Total)
It is an offence to deliberately make false statements to the Workplace Safety and Insurance Board. I hereby certify that the information
being submitted is true, correct and complete.
Signature:
Date (mm/dd/yy):
Name (please print):
3947A (06/16)
See instructions
on reverse.
For further information and/or inquiries, please see our website www.wsib.on.ca or call 1-800-387-0750.
Start >
START
ADDRESS
HERE >
Important: Do not use this form to bill for medical reports.
Important: Do not use this form to bill for medical reports.
See instructions
below
print
reset
print
reset
Type your name and upload, or print and sign before returning to WSIB.
Provider Payment Request Form
Important: Do not use the Provider Payment Request Form to bill for clinical reports.
INSTRUCTIONS
For prompt payment, complete as per the instructions given below.
WORKER INFORMATION
1. Claim Number: Enter worker's WSIB claim number. This is required to process the payment.
2 Name: Print Surname, Given Name(s) and Middle Initial.
3. Worker's Impairment and/or ICD 9 Code: Enter diagnosis or ICD 9 code for which treatment is being provided,
if available.
4. Date of Incident: Enter reported date of incident.
5. Address: Enter current mailing address.
6. Date of Birth: Enter birth date.
7. WSIB Reference No.: Please do not complete. For WSIB use only.
PROVIDER INFORMATION
8. Provider/Facility Name and Full Address: Enter the name and full address of the provider/facility submitting the bill.
9. WSIB Provider ID: Enter the 9 digit WSIB assigned billing number. This is required for payment.
10. HST Registration No: Enter your HST registration number, if HST is being billed (using service code ONHST).
11. Your Own Invoice No.: Enter your own invoice number. (Your reference number for reconciliation purposes.)
12. Treating Provider's Name: Enter the name of the individual providing the service/treatment.
13. Telephone Number: Provide the telephone number of the individual completing the payment request form.
SERVICE/TREATMENT INFORMATION
14. Service Code: Enter appropriate service code. Refer to the WSIB Fee Schedule.
15. Description of Service/Treatment: Provide a brief description of service/treatment provided.
16. Fee per Service: Enter fee per service/treatment from the appropriate WSIB Fee Schedule.
17. No. of Serv./Trt.: Enter the number of services/treatments that you are billing.
18. Amount Billed: Enter the total amount for the one service code.
19. Service Date: Enter month and year. Select date(s) of service by (ü). Use a separate line for each
month/service code.
20. Total Billed: Enter the total sum of all fees billed.
21. Name: Enter the name of the individual completing the form.
22. Signature & Date: Signature of individual completing the payment request form and date when completed.
For information on electronic billing, please contact Telus at 1-866-240-7492, via e-mail at
provider.mgmt@telus.com or visit their website at telushealth.com.
3947A2
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3947a Fs 06 16

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Completed 31 March 2021

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