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Get Canada WCB Alberta C568 2020-2023

Gender: Province Part of Body Side of Body Date of Service (yyyy/mm/dd) Health Service Code Female Postal Code Telephone Number Date of Referral Name of Referring Physician (yyyy/mm/dd) Date of Birth Male (yyyy/mm/dd) (yyyy/mm/dd) Date of Accident Nature of Injury Diagnostic Code Modifier Skill Code Calls Encounter Fees Submitted $ $ $ $ Total Amount Billed: Billing Number Contract ID Name and address to whom fee is payable: $ Facility Type Signature Printed Nam.

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