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Continuation portion 2026
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- Click ‘Get Form’ to open the continuation portion in the editor.
- Begin by entering the Doctor's Name in the designated field. This ensures that all services are correctly attributed.
- Input the Carrier Case Number and WCB Case Number. These identifiers are crucial for tracking and processing your claim.
- Fill in the Patient's information, including their Social Security Number, ensuring accuracy for verification purposes.
- Specify the Dates of Service by selecting the 'From' and 'To' dates using the date picker tool for convenience.
- Indicate the Place of Service by filling in the relevant details as required.
- Document the Date of Accident or Injury accurately to support your claim.
- List all Procedures, Services, or Supplies provided, along with their corresponding CPT/HCPCS codes and any applicable modifiers.
- Enter Diagnosis Codes as needed to clarify medical conditions related to services rendered.
- Finally, input Charges, Days or Units, and Zip Code where service was rendered to complete your submission.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2008 | 4.9 Satisfied (437 Votes) |
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