C1388
                                                                                                          PSYCHOLOGY SERVICES
           P.O. BOX 2415                                                                  MSW Counselling Services Invoice
           EDMONTON, AB  T5J 2S5
           FAX: (780) 427-5863
           1-800-661-1993
                                                                                                                               WCB Claim Number
          WORKER DETAILS                                                                                                            
          Surname                                First Name and Initial                      Date of Accident (yyyy/mm/dd)     Date of Birth 
                                                                                                                               (yyyy/mm/dd)
                                                                                                                                    
                                                                  SERVICE COMPONENTS
           Service Date                             Description                                      Service Code               Units          Fee
            (yyyy/mm/dd)                                                                       In-person          Virtual
                            Worker Counselling Session (per hour)                            ☐ MSW01         ☐ MSW01V                           $144.00
                            Worker Counselling Session (per hour)                            ☐ MSW01         ☐ MSW01V                           $144.00
                            Worker Counselling Session (per hour)                            ☐ MSW01         ☐ MSW01V                           $144.00
                            Worker Counselling Session (per hour)                            ☐ MSW01         ☐ MSW01V                           $144.00
                            Counselling + EMDR Session (flat fee)                            ☐ MSW08A ☐ MSW08V                                  $180.00
                            Counselling + EMDR Session (flat fee)                            ☐ MSW08A ☐ MSW08V                                  $180.00
                            Counselling + EMDR Session (flat fee)                            ☐ MSW08A ☐ MSW08V                                  $180.00
                            Counselling + EMDR Session (flat fee)                            ☐ MSW08A ☐ MSW08V                                  $180.00
                For Family Member/Joint Counselling Treatment Extension Request (please fill out the information below):
          Family Member’s Surname                         Family Member’s First Name                      Relationship of Family Member to Worker
                                                                                                               
           Service Date                              Description                                     Service Code                Units          Fee
            (yyyy/mm/dd)                                                                       In-person          Virtual
                            Family Member Counselling Session (per hour)                     ☐ MFC01         ☐ MFC01V                           $144.00
                            Family Member Counselling Session (per hour)                     ☐ MFC01         ☐ MFC01V                           $144.00
                            Joint Counselling Session (per hour)                             ☐ MJC01         ☐ MJC01V                           $144.00
                            Joint Counselling Session (per hour)                             ☐ MJC01         ☐ MJC01V                           $144.00
                            C1416 Family Member/Joint Treatment Extension                               ☐ PFC03                                   $25.00
                            Request
                                                        MISCELLANEOUS (See Legend on back)
          Start Date       End Date                                 Description                                 Service         # of       Amount
          (yyyy/mm/dd)     (yyyy/mm/dd)                                                                          Code          Units
                                                                                                                                              $     
                                                                                                                                              $     
                                                                                                                                              $     
                                                                                                                                              $     
                                                                                                         Total Amount Billed                   $     
          Masters Level Social Worker’s Name:                                      Signature
               
                                                                                   Print Name
          Address to Whom Fee is Payable (please print)                                 
                                                                                   Email Address                        Telephone Number
                                                                                                                             
          Billing Number:                                                          Provider’s Reference # (optional)    Date (yyyy/mm/dd)
                                                                                                                             
                      THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.
          C – 1388 REV JAN 2022                                                                                                                    Page 1 of 2
        MSW Counselling Services Invoice
        (Surname)                                (First Name)                               Claim Number
        SERVICE LEGEND
                     DESCRIPTION                        SERVICE CODE                                RATE
                                                   IN-PERSON       VIRTUAL
        WORKER PSYCHOLOGICAL SERVICE
        TPI Counselling Session                     MSWT01        MSWT01V       Hourly                               $144.00
        Worker No-show/Cancellation                 MSW01C        MSW01VC       Hourly                                $72.00
        Clinical Telephone Consultation             MSW09                       Per 15 mins (max 1 hour)              $36.00
        Worker Non-contracted Services                     MSWNCS               Hourly (HCC approval required) As approved
        FAMILY MEMBER/JOINT PSYCHOLOGICAL SERVICE
        Family Member/Joint No-                     MFC01C        MFC01VC       Hourly                                $72.00
        show/Cancellation
        Clinical Telephone Consultation              MFC02                      Per 15 mins (max 1 hour)              $36.00
        Family Member/Joint Non-contracted                 MFCNCS               Hourly (HCC approval required) As approved
        Services
        EXPENSES
        Professional Travel Time                    MSW04        $36.00 per 15 minutes
        Mileage                                      EXP01       $0.51 per km (Adjusted as per WCB rate)
        Breakfast                                    EXP02       $11.00 (Adjusted as per WCB rate)
        Lunch                                        EXP03       $14.00 (Adjusted as per WCB rate)
        Dinner                                       EXP04       $24.00 (Adjusted as per WCB rate)
        Other Travel Expenses – e.g., parking,       EXP10       As incurred (receipts must be retained for audit purposes)
        toll, air fare, hotel
        Billing Rules:
               All invoices must be submitted within six (6) months of date of service.
               Corrections must be submitted within two (2) months of being notified by WCB of an error.
               Corrections identified by the provider must be submitted within six (6) months of date of service.
                  THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.
        C - 1388 REV JAN 2022                                                                                            Page 2 of 2