Document bBGgkj2ZYzoeqDMZxgy8zQ6bD

n yOhio Bureau of I Workers' Compensation u ATTENDING PHYSICIAN'S -FEE BILL-- %J INSTRUCTIONS: Complete all applicable portions of this bill and mail to nearest district office of the Bureau of Workers' Compensation. * ^^our bill must be filed within 2 years from the date services were rendered. , 9 Name J_osep.h S_ ucci Z < Address 1767 Griggs Rd. City, State, Zip Code -J Jefferson. OH 44047____________________ ___ _ O Phone Number (optional) 'feTaas BWC Claim Number OD 34780-22 1. Give claimant's present condition/diagnosis. 2. Is present condition solely the result of the injury? DC YES NO if no, explain O a. LU DC 3. Does claimant have a disability as a result of the injury? YES NO if yes, complete all items below. C/J Check type of Give datefs) claimant was/will z Check One < o TemDorarv Check One Total Rehabilitation Recommended Med lea Both be able to return to work. Light Work C/3 > 4. Permanent _____ PartleL Give % of Disaiblltv * __________Vocational Physician's Remarks (Use reverse side of form if more space is required) None Regular Work 5. Are treatments soley for recognized conditions ? YES NO Date Of Service 9-8-86 to Place (Hospital, Office, Home) Service Detcription (Specify Part of Body Treated) 9-18-88 Hospital Hospital Care < N 9-23-88 Office Office Visit Ui 10-7-88 Office Office Visit U 10-17-88 Office Office Visit if no, indicate those which are not. Charges 283.06 Do Not Write In This Space -Received BWC- 18.00 18.00 18.00 m 11-10-88 Office Office Visit eS 14-17-88 Office Z LU s 11-28-88 Office I<- LU 12-8-88 Office DC 12-10-88 to Office Visit Office Visit Office Visit 12-14-88 Sospltal Hospital Care 12-22-88 Office Office Visit IAAR 3 gflffrfK'S REIMBURSEMENT: If any part of this bili has been paid indicate Amount 1989 PEE** 18.00 18.00 18.00 18.00 189-51 18.00 see next r"3 i '\ -n rn lJ r, -q F3 o (Name & Address) Address City, State, Zip Code B4YEE IDENTIFICATION (Payee No. must be present to process paymentj *Payee Number 47304-01 Billing Code/Dete (not to exceed 10 digits) 2-23-89 Federal I.D. No. (optional) 34-1398289 i neiouy csruiy trim ms nnvrniauun cu to the best of my knowledge and belief. Physician's Signature ~z*As/ft " Dnate * NOTE: This form must be signed In the Physician's own handwrlting-For fraud penalties see sections 2921.13, 2913.02. 2901.23, 2929.11.2929.21, and 2929.31 Ohio Revised code. Payee's name, address, city, state, zip code and phone No. (Please print, stamp, or type) f tJAfei AN S WAID. JR- M.D. IN^** 7 s bnESTNUT STREET *,V-\ JEFFERSON, OHIO- 44047 TELEPHONE (216) 570-9111 BWC USE NLY Use this section when denying or partially paying bill by codas 1-30 or Code 77 Use only the 70 spaces provided DCN Ah$ou&r CHARGED II'I III -1--1___I___L J____L I I l____I____L l l___ I I J___ I----- !----- 1___ I___ I J___ I___ L Code J___I___1___L EIN Stamp J-I I J____I Date J____L I I -I___ L Signature J__ L BWC-1124 (Rev. 9/83) C-19 DD/ag 2/14/89 - WH|iTEN SIGNATURE HAND V/Hl ` ` Completion of this form It required to receive payment of Heims GENC 002682 $ p ATTENDING PHYSICIAN'S ||OOhhlio Bureau oi 11 WWoorkers' Compensation INSTRUCTIONS: -FEE BILL- BWC Claim Number Complete all applicable portions of this bill and mall to nearest district office of the Bureau of Workers' Compensation. OD-34780-22 Your bill must be filed within 2 years from the date services were rendered. p# Name Joseph Succi H Z Address < 1767 Griqqs Road City, State, Zip Code < _j Jefferson, OH 44047 Name 0C LU General Tire > Address O _i Q. P.Q. Box 3545 s City, State. Zip Code UJ __________ Akron. OH 44309 o Phone Number (optional) Injury Date October of 1988 BWC USE ONLY R. M. 1. Give claimant's present condition/diagnosis. 2. Is present condition solely the result of the injury? occ Q. UJ CC 3. Does claimant have a disability as a result of the injury? YES YES I NO if no, explain _____ NO If yes, complete all items below. V Check type of z Check One Check One Rehabilitation Recommended < o TemDorarv Total Med lea Both 03 > X 4. Permanent Partial Give % of Disaiblitv 9(1 __________ Vocational ----------- tlszos Physician's Remarks (Use reverse side of form if more space is required) a. Give datefs) claimant was/will be able to return to work Lioht Work Regular Work 5. Are treatments soley for recognized conditions ? YES NO Date Of Service Place (Hospital, Office, Home) Service Description (Specify Part of Body Treated) if no, indicate those which are not. Charges J.T, Do Not Write , t\ In This Space ^--Received BWC- 12-30-88 Office Office Visit < 1-1-89 To N 1-8-89 ; fospital Hospital Care ui O Z 18.00 370.95 \\6 CO <3 z UJ Y< UJ DC REIMBURSEMENT: |f any,part of this bill has been paid indicate Amount Designate by whom paid - Name Joseph Succi________ (Name & Address) ^ 1767 Griggs Road City, State, Zip Code Jefferson. OH 44047 I'AYEE IDENTIFICATION (Payee No. must be present to process payment) AMOUNT CHARGED Payee Number 47304-01 Billing Code/Dete (not to exceed 10 digits) 2-23-89 Federal i.D. No, (optional) 34-1398289 I hereby certify that the information contained on this form is true and correct Payee's name, address, city, state, zip code and phone No. to the best of my knowledge and belief. (Pleaseprint, stamp, or type) ! HARLAN S. WA1D, JR- M.D. INC. Physician's Signature Date V x 125 S. CHESTNUT STREET N UEFFERSON, OHIO-44047 NOTE: This form must be signed in the Physician's own handwriting-For fraud penalties see sections 2921.13, 2913.02. 2901.23,2929.11,2929.21. and 2929.31 Ohio Revised code. V;'> TELEPHONE (216) 576-9111 BWC USE ONLY -------- RECEIVE! *Use this section when denying or partially paying bill by codes 1-30 or Code 77 * use omy me /u spaces provioea MAR 3 198 3 DON : 1____!____L 1 i l____I t __i_ 1 1 1 1 1 1 1 1 t Pi____l___i____i___ i___ i____i____i____L__l____L_. J____1____1____1____1____l_ J -U--I.___ 1____1___ 1___ _i___ i___ i___ i___ i___ i__ J___ 1___ 1 l t WUKhtK S LUMPOtfSATIUh JJEP). L___ 1___ I 1 1 1 J____1___ 1___ 1___ 1___ 1___ J___ 1___ 1___ 1___ 1 Code EIN Stamp Date Signature BWC-1124 (Rev. 9/83) C-19 Completion of this form is required t( receive payment of claims GENIC 002683 #