Health care providers and clinics that do not bill the WSIB electronically through TELUS Health can request payment for services on this form. Each line takes one WSIB service code with its fee, the number of services and the dates given, and the lines add up to a total billed. It is not for medical reports, which are billed on the WSIB report form itself.
The provider or clinic completes the whole form: the worker's claim number and details, the provider's 9-digit WSIB Provider ID, HST and invoice numbers, the service lines, and a certification, signed by the person completing it, that the information is true, correct and complete.
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No. The WSIB says not to use the Provider Payment Request to bill for medical reports. Bill a report through the billing section on the pre-printed WSIB report form, or place a payment label on the front page, bottom right corner, of a narrative report.
Enter the worker's claim number, name, date of birth, date of incident and, if available, the diagnosis or ICD 9 code, then your WSIB Provider ID and invoice number. Use one line per service code and month, with the fee from the WSIB Fee Schedule, the number of services and the dates, and sign the certification.
The WSIB directs providers to TELUS Health to submit invoices and to register to bill and get paid online. Form 3947A is the alternative, submitted through the WSIB's online submission page with an online services login. Payment requests for equipment and supplies use the separate form 3941A.