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Worker Details: C1303 Home Health Care Services Invoice Correction

This document is an invoice correction form for home health care services related to a WCB claim. It requires details about the worker, the original invoice, and specific corrections for services billed incorrectly or not billed at all. Corrections must be submitted within two months of notification of an error by WCB.

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Dawn Casuncad
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33 views1 page

Worker Details: C1303 Home Health Care Services Invoice Correction

This document is an invoice correction form for home health care services related to a WCB claim. It requires details about the worker, the original invoice, and specific corrections for services billed incorrectly or not billed at all. Corrections must be submitted within two months of notification of an error by WCB.

Uploaded by

Dawn Casuncad
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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C1303

HOME HEALTH CARE SERVICES


P.O. BOX 2415
EDMONTON, AB T5J 2S5 Invoice Correction
FAX: 780 427-5863
1-800-661-1993

WCB Claim Number


Please print clearly or type.
WORKER DETAILS
Date Originally Submitted Invoice Number Date of Accident (yyyy/mm/dd)

Surname First Name and Initial Date of Birth (yyyy/mm/dd)

Address City/Town Province Postal Code Telephone Number

Please submit only one Invoice Correction per Date of Service


CORRECTIONS
Service Number of
Description Amount
Code Units
If the service was not previously billed:
Should be: Date of Service
Should be: Date of Service
Should be: Date of Service

If the service was previously billed incorrectly:


Was: Date of Service
Should be: Date of Service

Was: Date of Service


Should be: Date of Service

Was: Date of Service


Should be: Date of Service

ADDITIONAL COMMENTS

Name and Address to Whom Fee is Payable (print) Signature

Print Name

Telephone Number Fax Number

Provider Reference Number Date (yyyy/mm/dd)


WCB Billing Number:

THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.
CORRECTIONS MUST BE SUBMITTED WITHIN 2 MONTHS OF BEING NOTIFIED BY WCB OF AN ERROR.
C – 1303 JUNE 2020 Page 1 of 1

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