Generic Invoice for Medical and Health Care

PAYMENT SERVICES Phone 604 276-3085 Toll-free 1 888 422-2228 Invoice number FAX 604 233-9777 Toll-free 1 888 922-8807 Invoice date (yyyy-mm-dd) MAIL Payment Services, WorkSafeBC PO Box 4700 Stn Terminal Vancouver BC V6B 1J1 Contract ID Authorization number Payee name Payee number GST registration number Mailing address for payment City Province Telephone number (please include area code) Fax number (please include area code) Payment information Postal code Service recipient information (worker or other person who received service) Service recipient last name Service recipient first name Service recipient date of birth (yyyy-mm-dd) Service recipient personal health number (CareCard number) WorkSafeBC claim number Date of injury (yyyy-mm-dd) Service information Date of service (yyyy-mm-dd) Number of items Fee code Description (number of units) Cost per unit Line item amount PST GST (not including taxes) (if charged) (if charged) Line item total (including taxes) Invoice total Personal information on this form is collected for the purposes of administering a worker’s compensation claim by WorkSafeBC in accordance with the Workers Compensation Act and the Freedom of Information and Protection of Privacy Act..