C537A
                                                                                PROSTHETIC AND ORTHOTIC SERVICES
           P.O. BOX 2415                                            Unlisted Device/Service Calculations Worksheet
           EDMONTON, AB  T5J 2S5
           FAX: 780-427-5863
                1-800-661-1993
                                                                                                                            WCB Claim Number
            WORKER DETAILS                                                                                                       
            Surname                                               First Name and Initial                                    Date of Birth (yyyy/mm/dd)
                                                                                                                                 
                                                                                            Date of Service (yyyy/mm/dd)    Date of Accident (yyyy/mm/dd)
                                                                                                                                 
          Please use this calculation worksheet to determine pricing for unlisted devices/services.
            NOTE: For unlisted socks, sheaths, or sleeves ONLY, please enter the Invoice Price into Line B.  Otherwise, leave this space blank.
                                                   ONLY Line A OR Line B should be completed – NOT both.
                                                     Manufacturer’s Invoice or Quote must be attached
          Code:                   Item Description:                                          Quantity:               *Invoice Price:      $      
          *If invoice price is in USD, please use the Bank of Canada exchange rate from the date of invoice and enter amounts in CAD.
          A.    Mark-up *excluding unlisted socks, sheaths, sleeves                                           (Invoice Price x .12)    $ 0.00.00
                $ 0.00  Invoice Price (If any taxes on invoice please exclude and show tax on line D)
          B.    Mark-up for unlisted socks, sheaths, or sleeves ONLY                                          (Invoice Price x .70)    $ 0.00.00
                $ 0.00  Invoice Price (If any taxes on invoice please exclude and show tax on line D)
          C.    Shipping, as per invoice:  0.00                                                        (Shipping actual cost x 1.12) $ 0.00.00
          D.    Taxes Paid, as per invoice                                                                  (Enter actual tax paid)    $ 0.00
          E.    Labour (please use up to the closest ¼ hour multiplied by $185.77 per hour)                                            $ 0.00.00
                Indicate time needed: 0.00 (hrs and or portion)
                                                      **Self-Calculated total price: Invoice Price + A + B + C + D + E = $ 0.00.00
                                                                            0Please use a C537 invoice to claim this amount
          Name and address to whom fee is payable (please print).            Provider Signature
                                                                                       
                                                                             Print Name
                                                                                  
          WCB Billing Number:                                                Phone Number                           Fax Number
                                                                                                                         
                                                                             Date (yyyy/mm/dd)                      Provider’s Reference Number
                                                                                                                         
                      THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.
                                  INVOICE MUST BE SUBMITTED WITHIN 6 MONTHS OF SERVICE TO BE ELIGIBLE FOR PAYMENT.
          C – 537A REV APR 2021                                                                                                                    Page 1 of 1