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Auto Insurance Standard Invoice

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Auto Insurance Standard Invoice Page 2
Auto Insurance Standard Invoice
OCF-21 - Version A - page 2
This form may be used for billing goods and services that have been previously approved by the insurer through an OCF-18.
This form may not be used for Minor Injury Guideline or Pre-approved Frameworks Treatments (use Version C - pages 2 and 3) or goods and services that have not been previously approved (use Version B - pages 2 and 3).
Injuries and Sequelae Providers
Regulated
(College Registration
Number)
Unregulated
(AISI Number if
applicable, or blank)
Hourly Rate For Insurer's
Use
Description
Code
Ref
Type Last Name First Name
A
B
C
D
E
F
Injury details are not required if they are the same as those on an approved plan.
Refer to the User Manual at www.hcaiinfo.ca for coding.
Provider details are not required if they are the same as those on an approved plan.
Refer to the User Manual at www.hcaiinfo.ca for coding.
G/S
Ref
Month (yyyy-mm):
Tax
Cost/
Day
Total
Count
Total
Cost
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Refer to the previously approved plan for each good and service reference number (G/S Ref).
Enter the Provider Reference from the previously approved plan or the Provider table above at the intersection of the date of service and the G/S Ref indicating the provider who rendered or prescribed the service or good.
Other Insurance
(for goods and services
on this invoice)
MOH Insurer 1 Insurer 2
Account Activity since Last Invoice
(if interest is being charged)
Sub-Total:
Chiropractic:
MOH:
Physiotherapy: Prior Balance:
Other Insurer 1 + 2:
Massage Therapy:
Payment Received
from Auto Insurer:
Tax (if applicable):
1
Other Service Type:
Total:
2
Overdue Amount:
2
Interest:
1
Please Specify Other
Service Type:
2
The insurer shall pay interest on overdue outstanding
balances as required by the Statutory Accident Benefits
Schedule.
Auto Insurer Total:
Make cheque payable to:
***Other Information:
Are there any attachments
Yes No
If yes, how many _______
Send an
y
attachments directl
y
to the insurer
For insurer's use only
Reviewed By:
Approved By:
Payee Name:
Payment Amount:
Total: Interest: Grand Total:
Effective date (2010/09/01)
OCF-21
FSCO 1208E
Page 2 of 6
SAVE
Auto Insurance Standard Invoice