Provider Payment Request Form
Important: Do not use the Provider Payment Request Form to bill for clinical reports.
For prompt payment, complete as per the instructions given below.
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,
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.
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.
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
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
firstname.lastname@example.org or visit their website at telushealth.com.