Form Wscd-6n - Claim For Non-Medical Services

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STATE OF WYOMING
DEPARTMENT OF WORKFORCE SERVICES
DIVISION OF WORKERS' COMPENSATION
CLAIM FOR NON-MEDICAL SERVICES
307-777-7441
PLEASE PRINT OR TYPE IN BLACK INK
Injured Worker Information
Payee Information
CLAIM #
FEDERAL TAX ID # OR
SOCIAL SECURITY #
Required for payment
SSN #
DATE OF BIRTH
NAME
DATE OF INJURY
ADDRESS
NAME
CITY
STATE
ZIP
ADDRESS
STATE
ZIP
PHONE # (
)
CITY
DESCRIPTION: Please provide a detailed description of services
rendered. Also attach any related documents which may clarify, explain,
DATES OF SERVICE
or support the charges being billed.
AMOUNT SUBMITTED
FROM
TO
I hereby certify under penalty of perjury, that all items billed above were rendered solely on account
TOTAL
of the original compensable injury and are true, accurate and complete to the best of my knowledge.
Payee Signature (required)
Date
INSTRUCTIONS FOR FILING:
Submit billing no later than the 30th of each month for prior month's
services or CLAIM MAY BE DENIED
MAIL ORIGINAL TO: Division of Workers' Compensation
PO Box 20070
Cheyenne, WY 82003-7001
WSCD-6N (Rev 12/11)

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