(1) The individual's or entity's provider tax identification number, professional photocopier registration number, county of registration, and date of billing;
(2) The injured worker's name, claim number, and Workers' Compensation Appeals Board case number (if applicable); and
(3) The source of the information, the type of records produced, the date of service, a description of the billed services, the number of pages produced, and a statement that the services described in the bill are neither related to nor the result of a violation of Labor Code section 139.32.