Form F245-030-000 "Statement for Retraining and Job Modification Services" - Washington

What Is Form F245-030-000?

This is a legal form that was released by the Washington State Department of Labor and Industries - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2017;
  • The latest edition provided by the Washington State Department of Labor and Industries;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F245-030-000 by clicking the link below or browse more documents and templates provided by the Washington State Department of Labor and Industries.

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Download Form F245-030-000 "Statement for Retraining and Job Modification Services" - Washington

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Statement for Retraining and Job
Modification Services
Mail completed form to:
To bill for Option 2 training, use the Statement for Option 2 Training
PO Box 44269
(F245-446-000) form.
Olympia WA 98504-4269
Worker Information ― Required (Please Print)
Claim No.
Name (Last, First, Middle Initial)
Date of Injury
Home Address
Apt #
Social Security No. (For ID Only)
City
State
Zip Code
Phone Number
Provider Information (Please Print)
L&I Provider Number
Name (Last, First, Middle Initial)
Federal Tax ID
Address
Phone Number
City
State
Zip Code
Vocational Rehabilitation Counselor Information
Referral ID
Vocational Rehabilitation Counselor Name
VRC ID (L&I Provider Number)
Billing Information (See Back for Instructions)
From
To Date
POS
TOS
Procedure
Description of Services or Supplies
Units
Charges
Date of
of
Code
Service
Service
99
V
1
99
V
2
99
V
3
99
V
4
99
V
5
99
V
6
99
V
7
99
V
8
99
V
9
99
V
10
Total Charge
Signature (Only one signature is required. Sign under the appropriate section)
$
Is this a bill to reimburse the worker?
Is this a bill for provider payment?
Yes ― Include copies of receipts and sign below.
Yes ― Sign below.
These expenses are related to my workers’ compensation
I certify that the information in the bill is true and correct.
claim and I have not been reimbursed for them. I
I have not been reimbursed for any part of this bill.
understand it is a crime to submit information I know is
false.
Worker’s Signature
Date
Provider’s Signature
Date
F245-030-000 Statement for Retraining and Job Modification Services 12-2017
RESET
Statement for Retraining and Job
Modification Services
Mail completed form to:
To bill for Option 2 training, use the Statement for Option 2 Training
PO Box 44269
(F245-446-000) form.
Olympia WA 98504-4269
Worker Information ― Required (Please Print)
Claim No.
Name (Last, First, Middle Initial)
Date of Injury
Home Address
Apt #
Social Security No. (For ID Only)
City
State
Zip Code
Phone Number
Provider Information (Please Print)
L&I Provider Number
Name (Last, First, Middle Initial)
Federal Tax ID
Address
Phone Number
City
State
Zip Code
Vocational Rehabilitation Counselor Information
Referral ID
Vocational Rehabilitation Counselor Name
VRC ID (L&I Provider Number)
Billing Information (See Back for Instructions)
From
To Date
POS
TOS
Procedure
Description of Services or Supplies
Units
Charges
Date of
of
Code
Service
Service
99
V
1
99
V
2
99
V
3
99
V
4
99
V
5
99
V
6
99
V
7
99
V
8
99
V
9
99
V
10
Total Charge
Signature (Only one signature is required. Sign under the appropriate section)
$
Is this a bill to reimburse the worker?
Is this a bill for provider payment?
Yes ― Include copies of receipts and sign below.
Yes ― Sign below.
These expenses are related to my workers’ compensation
I certify that the information in the bill is true and correct.
claim and I have not been reimbursed for them. I
I have not been reimbursed for any part of this bill.
understand it is a crime to submit information I know is
false.
Worker’s Signature
Date
Provider’s Signature
Date
F245-030-000 Statement for Retraining and Job Modification Services 12-2017
RESET
Instructions for Completing the Statement for Retraining and Job Modification Services
To bill for Option 2 training, use the Statement for Option 2 Training (F245-446-000) form.
Worker Information
Claim Number
Enter the worker’s L&I claim number.
Name
Write the worker’s legal name in the last name, first name, middle initial format.
Date of Injury
Enter the date of injury.
Home Address
Write the most current physical address of the worker.
Social Security Number
Enter the worker’s Social Security Number. Used to verify the claim number.
Phone Number
Enter the phone number where the agency can call if there are any question about
this bill.
Provider Information
L&I Provider Number
Enter the provider’s L&I provider number.
Provider Name
Write the provider’s name as registered with the department.
Provider Address
Write the provider’s address.
Federal Tax ID
Enter the Federal Tax ID (EIN) for the billing provider. This must match the EIN on
file with the agency.
Phone Number
Enter the phone number where the agency can call if there are any question about
this bill.
Vocational Rehabilitation Counselor Information
Referral ID
Write the Referral ID.
Vocational Rehabilitation
Write the provider’s name as registered with the department.
Counselor Name
VCR ID
Write the VCR ID. This is the L&I provider number for the VRC.
Bill Information ― Use one line for each service provided. Complete each applicable field.
From Date of Service
Enter the starting date of service.
To Date of Service
Enter the ending date of service.
Procedure Code
Enter the appropriate code from the list below. One code per line.
Description
Write a brief description of the services provided.
Units
Enter the total number of units you are billing for.
Charges
Enter the charge for each service provided.
Total Charges
Enter the total for all of the charges on the bill.
Retraining Codes
Job Modification/Pre-Job
Lodging and Retraining
Retraining Codes:
Retraining Transportation
Accommodation Codes:
Codes:
Codes:
0380R ― Job Modification
R0360 ― Board (food) and
R0310 ― Tuition, training
0302R ― Parking
equipment
utilities
fees
0303R ― Bridge and ferry
0385R ― Pre-job
R0370 ― Rent
R0312 ― Supplies ―
toll
accommodation equipment
0375R ― One-time
equipment, tools, books
0304R ― Commercial
0389R ― Job
relocation fee (for life of
R0320 ― Exam, license
transportation
Modification/Pre-job
claim)
fee
accommodation
R0350 ― Other
consultation
R0390 ― Child care
0391R ― Travel/Wait
services
0392R ― Mileage
0393R ― Ferry
Signature ― Only one signature is required.
Worker Signature
If the bill is to reimburse the worker, the worker must sign and date the form. Attach
copies of the receipts. All receipts must be itemized and legible.
Provider Signature
If the bill is to reimburse the provider, the provider must sign and date the form.
F245-030-000 Statement for Retraining and Job Modification Services 12-2017
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