[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-335637-105":53,"doc-detail-335637-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","physical-therapy-services-invoice-read-online-free","Physical Therapy Services Invoice - read online free","","Physical Therapy Services Invoice is a billing template for physical therapy providers to document and submit charges for services related to a Workers’ Compensation (WCB) claim. It captures worker details, WCB claim number, date of accident, date of birth, and contact information, then lists service items with health service codes, descriptions, quantities, rates per unit, and fees submitted. The invoice also includes provider payout information and a service legend with effective fees, including chart copies and chart summaries, plus codes for miscellaneous sundry items and non-contracted services.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":21,"@type":70,"position":76},"https://docshare.wps.com/template/invoices/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/physical-therapy-services-invoice-read-online-free/335637/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/physical-therapy-services-invoice-read-online-free/335637.png","ImageObject",442,249,{"name":88,"@type":89},"Caleb Sterling","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-16","2026-09-21",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required for worker details on the Physical Therapy Services Invoice?","Question",{"text":108,"@type":109},"The form requests surname, first name and initial, address street, city/town, date of birth, and telephone number, alongside the worker’s WCB claim number and date of accident.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How are service items recorded on the invoice?",{"text":113,"@type":109},"Service items are entered with a date of service, health service code, description, quantity, rate per unit, and fee submitted, with totals billed shown for each section.",{"name":115,"@type":106,"acceptedAnswer":116},"What does the service legend provide?",{"text":117,"@type":109},"The service legend lists health service codes (such as RF04, RF05, RF06, NCPTS, and NCS), the associated service definitions, and the fee schedule effective February 1, 2017.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},335637,1791393203,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":20,"category_name":21,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},962084925290,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","C019  \nPHYSICAL THERAPY SERVICES  \nP.O. BOX 2415  \nEDMONTON, AB T5J 2S5  \nFAX: 780-427-5863  \n1-800-661-1993  \nInvoice  \nPlease printclearly or type.  \n\n| WORKER DETAILS | WCB Claim Number | Date of Accident (yyyy/mm/dd) |\n| --- | --- | --- |\n| Surname | First Name and Initial | Dateof Birth (yyyy/mm/dd) |\n| Address Street | City/Town | Telephone Number |\n\nService Items  \nDate of Service  \n(yyyy/mm/dd)  \nSundry Items  \n\n|  | Health\u003Cbr>Service Code | Description | Quantity | Rate per Unit | Fee\u003Cbr>Submitted |\n| --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  | Total Amount Billed |  |\n\n\n| Date of Service\u003Cbr>(yyyy/mm/dd) | Health\u003Cbr>Service Code | Description | Quantity | Fee\u003Cbr>Submitted |\n| --- | --- | --- | --- | --- |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  | Total Amount Billed |  |\n\n\n| Name and Address to Whom Fee is Payable\u003Cbr>WCB Billing Number: | Provider Name |  |\n| --- | --- | --- |\n|  | Print Name |  |\n|  | Telephone Number | Fax Number |\n|  | Provider Reference Number | Date (yyyy/mm/dd) |\n\nNOTE: PLEASE SEE REVERSE FOR SERVICE LEGEND  \nTHIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.  \nC-019 REV JUNE 2020 Page 1 of 2  \nPhysical Therapy Services Invoice  \nSERVICE LEGEND  \n\n| Health Service Code | Service | Fee (Effective February 1, 2017) |\n| --- | --- | --- |\n| RF04 | Chart Copies requested by the WCB | $26.52 for the first page plus $0.47 per page thereafter |\n| RF05 | Summary of chart information, requiring the extraction of relevant information but not an opinion | $93.15 for the first thirty (30) minutes plus $36.23 for each additional fifteen (15) minute increment |\n| RF06 | Summary of chart information, requiring the extraction of relevant information and including an opinion | $113.85 for the first thirty (30) minutes plus $36.23 for each additional fifteen (15) minute increment |\n| NCPTS | Miscellaneous PT sundry item(s) not listed in the current contract | Miscellaneous sundry item code that can be used without prior approval, for any items up to a $20.00 value\u003Cbr>This code may be used for any individual item less than $20.00 and is not capped at $20.00 per case\u003Cbr>The Contractor shall bill the actual direct cost of the item and shall retain the original receipt on file and shall be submitted upon request.\u003Cbr>The Contractor shall include a description of the item when invoicing and shall bill using the C019 PT paper invoice |\n| NCS | Non-contracted service | For non-listed sundry items greater than $20.00. Requires prior PT Consultant approval\u003Cbr>For non-contracted service(s), requires prior WCB Health Care Consultant approval |\n\nTHIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.  \nC-019 REV JUNE 2020 Page 2 of 2","cbCaiayA5XYH2nic","https://ap.wps.com/l/cbCaiayA5XYH2nic","pdf",214315,"English","# Invoice Header and Claim Information\n## Worker Details\n## Service Items (Line Items)\n## Provider and Payment Details\n## Service Legend (Health Service Codes and Fees)","[{\"question\":\"What information is required for worker details on the Physical Therapy Services Invoice?\",\"answer\":\"The form requests surname, first name and initial, address street, city/town, date of birth, and telephone number, alongside the worker’s WCB claim number and date of accident.\"},{\"question\":\"How are service items recorded on the invoice?\",\"answer\":\"Service items are entered with a date of service, health service code, description, quantity, rate per unit, and fee submitted, with totals billed shown for each section.\"},{\"question\":\"What does the service legend provide?\",\"answer\":\"The service legend lists health service codes (such as RF04, RF05, RF06, NCPTS, and NCS), the associated service definitions, and the fee schedule effective February 1, 2017.\"}]","Physical Therapy Services Invoice - read online free | PDF",1790011746]