If you plan to submit an outdated version of the Washington Provider Application, you must:

1. Initial any changes, sign and date the application.
2. Give us additional information that is missing from older forms by completing, signing and submitting one of the following documents:
   • 2009 WPA missing data (188 KB Word doc)
   • 2007 WPA missing data (244 KB Word doc)
   • 2005 WPA missing data (289 KB Word doc)

Questions?

Contact us:

• Phone: 360-902-5140
• Email: ProvNet@Lni.wa.gov