Surgeons and surgical assistants bill WorkSafeNB on this one-page form for surgery on an injured worker with a claim. Each procedure goes on its own line with its Medicare code, Medicare Manual units, adjusted units, unit rate and fee, marked as the primary surgery or a secondary procedure through the same or a different incision. Adjustments for after-hours or expedited surgery follow the total.
The primary surgeon, a GP or specialist surgical assistant, or a surgeon in collaborative surgery ticks their role, completes and signs the form, and adds the office stamp or address. It also needs the claim and Medicare numbers, the diagnosis, the surgery date and start time, and the surgery authorization number.
Download the current version from the source each time; forms change without notice.
Surgery Billing Form for WorkSafeNB Claimants
Formulaire de facturation pour la chirurgie à l'intention des travailleurs blessés de Travail sécuritaire NB
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.
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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For elective surgery and for collaborative surgery, yes: the form states that both must be pre-authorized, and the surgery authorization number goes in the header. Major surgery is billed on this form rather than the Doctor's Account, and the related anaesthesia is billed separately on WorkSafeNB's Anaesthesia Billing Form.
On the same Surgery Billing Form: tick surgical assistant GP or surgical assistant specialist, list each procedure with its unadjusted Medicare code and Medicare Manual units, and enter the adjusted units for surgical assistance. The form says WorkSafeNB uses the Medicare Manual to guide its payment for surgical procedures.
Yes. WorkSafeNB publishes a French version, the Formulaire de facturation pour la chirurgie à l'intention des travailleurs blessés de Travail sécuritaire NB, alongside the English form revised in February 2012. Both are listed on WorkSafeNB's health care forms page with its other physician billing forms.