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WorkSafeNB Anaesthesia Billing Form for Claimants

Anaesthesiologists bill WorkSafeNB on this one-page form for anaesthesia given to an injured worker with a claim. It itemizes primary basic and time units, modifiers such as morbid obesity, patient-controlled analgesia and additional procedures, then adjusts for after-hours work or a second anaesthetist. WorkSafeNB uses the Medicare Manual to guide its payment, and its system calculates the filing bonus automatically.

Who completes it

The anaesthesiologist completes and signs the whole form, declaring the services were rendered by them and not already paid, and adds the office stamp or address. It needs the claim and Medicare numbers, the surgery authorization number, the anaesthesia start time and the duration.

Submitting and payment

How to submit it
Fax it to WorkSafeNB, as the form directs, or mail it, but not both. WorkSafeNB's Doctor's Account form notes that, under the Act, payment must be requested within three months of the service.
Who pays
WorkSafeNB pays from the Medicare codes, units and unit rates entered on the form, using the Medicare Manual as its guide, and its system adds any filing bonus.

Good to know

  • Use a separate form for each anaesthetic when multiple or bilateral procedures are done at separate times under separate anaesthesias.
  • Rows 1 to 5 take the primary basic units, time units and modifiers; rows 6 and 7 take added procedures at the anaesthesia unit rate, and rows 10 to 12 those at the general rate.
  • Patient-controlled analgesia goes in rows 8 (initiation) and 9 (maintenance), with the number of days, the unit rate and the fee.
  • Tick when a second anaesthetist was required and attach the justification; the form also records after-hours and second-anaesthetist adjustments to the amount submitted.

Get the official form

Download the current version from the source each time; forms change without notice.

Anaesthesia Billing Form for WorkSafeNB Claimants

Formulaire de facturation pour l'anesthésie à l'intention des travailleurs blessés de Travail sécuritaire NB

Official pagePDFVersion française

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

How do I bill WorkSafeNB for anaesthesia on a surgical claim?

On the Anaesthesia Billing Form for WorkSafeNB Claimants, not the Doctor's Account, which tells physicians to bill major surgery and the related anaesthesia on their own forms. List the Medicare codes and units for the primary anaesthetic, any modifiers, PCA days and added procedures, sign the declaration and fax the form to WorkSafeNB.

Does WorkSafeNB pay a filing bonus on anaesthesia bills?

The form says WorkSafeNB's system calculates the filing bonus automatically, so you enter only the Medicare codes, units, unit rates and fees. Bill promptly: WorkSafeNB's Doctor's Account form notes that, under the Act, an application for payment must be made within three months of the service.

Is the WorkSafeNB anaesthesia billing form available in French?

Yes. WorkSafeNB publishes it in English and in French, as the Formulaire de facturation pour l'anesthésie à l'intention des travailleurs blessés de Travail sécuritaire NB. Both are one-page PDFs on WorkSafeNB's health care forms page, listed with its other physician billing forms; the English version was revised in March 2012.