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(R04/13) Page 1 of 1 Workers’ Compensation Board of B.C. 83D128
GENERIC INVOICE
—
MEDICAL AND HEALTH CARE
This invoice must be submitted within 90 days of the date of service. All fields with * are required for payment to be
processed. Failure to provide this information may result in processing delays or in non-payment. All other fields to be
completed (if possible). Incomplete invoices may be returned for resubmission.
PAYMENT SERVICES FAX MAIL
Phone 604 276-3085 604 233-9777 Payment Services, WorkSafeBC
Toll-free 1 888 422-2228 Toll-free 1 888 922-8807 PO Box 4700 Stn Terminal
Vancouver BC V6B 1J1
Invoice number
Invoice date* (yyyy-mm-dd)
Contract ID
Authorization number
Payment information
Payee name
Payee number*
GST registration number
Mailing address for payment
City
Province
Postal code*
Telephone number (please include area code)
Fax number (please include area 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)
Fee code* Description*
Number
of items*
(number of
units)
Cost per
unit*
Line item
amount*
(not including
taxes)
PST
(if
charged)
GST
(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. For further information about the collection of personal information, please contact WorkSafeBC’s Freedom of
Information Coordinator at PO Box 2310 Stn Terminal, Vancouver BC, V6B 3W5, or telephone 604 279-8171.
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